New Cotiviti Research Captures Healthcare Payer Shift From Postpay to Prepay Claim Integrity

• Survey of >100 health plan leaders offers insight into the challenges of balancing prospective and retrospective approaches across enterprise payment integrity programs

Cotiviti, a leader in data-driven healthcare solutions, has published new research capturing the healthcare payer industry’s challenges in optimizing pre and postpay claim payment integrity programs. The report, “Optimizing Payment Integrity with Enterprise Pre and Postpayment Solutions,” is based on a survey of 104 health plan stakeholders from more than 70 different payer organizations, conducted in partnership with HealthPayerIntelligence.

@Cotiviti publishes new research capturing the healthcare payer industry’s challenges in optimizing pre and postpay claim payment integrity programs, based on a survey of >100 health plan leaders

Among the key findings are:

• 80% of respondents say providers have responded positively or very positively to the shift from postpay to prepay integrity
• 28% of respondents say that misaligned third-party vendors have disrupted their efforts to shift from postpay to prepay integrity
• High accuracy is the most important factor in prepayment integrity solutions according to respondents, followed by average savings rate and integration with providers

“Health plans are increasingly finding that catching potential errors before claims are paid improves their financial performance by reducing overpayments while minimizing provider abrasion,” said Jordan Bazinsky, executive vice president of Cotiviti. “However, finding the right balance between retrospective and prospective payment integrity remains a challenge, and is frequently hampered by insufficient resources and lack of coordination among payment integrity vendors. This report ultimately confirms that payers need to take a unified, enterprise-level approach to payment integrity by deploying the right solution at the right time and removing silos between their pre and postpay teams and programs.”

Just 21% of surveyed health plan leaders say that more than half of their payment integrity is currently performed through prepayment intervention, though that figure is expected to rise to 30% within the next three years. The survey also found 54% are currently performing prepay intervention for coordination of benefits; 43% are performing prepay manual review of professional and outpatient claims with the member’s medical record; and 37% are performing prepay fraud, waste, and abuse detection.

In addition to misaligned vendors, major challenges health plans have encountered in implementing prepayment strategies were COVID-19 disruption (70%), risk of provider appeals (28%), insufficient resources (27%), and misaligned incentives between pre and postpay teams (25%).

“The biggest barrier [to prepay intervention] would be making sure we get efficient processes through our systems and that we don’t disrupt the payment model too much,” stated one managed care plan’s chief financial officer who was interviewed as part of the survey. “We’re looking for automation as much as possible. We’ll probably invest in a few more staff resources, but for the most part, we’re going to try it from an automated standpoint.”