U.S. Health Insurance: Payment Integrity and Fraud in Claim Adjudication

Technology tools can help health plans review claims and ensure accurate payments to healthcare providers.

Boston, July 16, 2020 – Healthcare payers are under pressure to control costs, and payment integrity plays an important role in those efforts. Verifying the validity of claims is a daunting task, however, and identifying fraud, waste, and abuse is only becoming more complex. Fortunately, technology for payment integrity is evolving.

This report analyzes the current and future state in payment integrity and in the underlying claims processing workflow. Based on interviews that Aite Group conducted between Q4 2019 and Q2 2020 with 36 executives from payment integrity, payment accuracy, fraud, claims processing, and identity verification vendors as well as U.S. health plan executives, it presents insights on health plans’ position on payment integrity and reveals what they want from their technology vendor partners.

This 40-page Impact Report contains 13 figures and eight tables. Clients of Aite Group’s Health Insurance or Fraud & AML service can download this report, the corresponding charts, and the Executive Impact Deck.

This report mentions Accent, Brighterion, Centers for Medicare and Medicaid Services (CMS), CGI Group, Change Healthcare, Cotiviti, Council for Affordable Quality Healthcare (CAQH), Equian, EXL, Experian Health, FairWarning, HealthcareFraudShield, HMS, LexisNexis Risk Solutions, Mastercard Healthcare Solutions, Optum, Shift Technology, SCIO Analytics, U.S. Department of Justice, Verscend Technologies, and Veritas Capital.

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