3 Payment Integrity Imperatives in Post-Pandemic Healthcare



December 16, 2021

Even pre-COVID-19, claims fraud, waste, and abuse (FWA) was a top-of-the-agenda issue for health plans aiming to evolve both care quality and consumer experience expectations. But the pandemic has surely raised the stakes for a need for a whole new payment integrity (PI) architecture, including complete process re-engineering and AI, automation, and analytics enablement. Health plans are grappling with compounding operational challenges — from aberrant services related to COVID-19 diagnoses to service shifts, uncontrolled telehealth expansion and, of course, labor shortages.

How can payers precisely address payment integrity needs while also strategizing healthy fiscal futures?

Here we provide three factors of the heightened PI pressures, with guidance on how PI solution experts can help.

1. Volume fluctuations and resource challenges

Complications affecting accurate forecasting of utilization and payments include excessive COVID-19 diagnosis, extended visit durations and increased visits for therapies, and early refills and disbursement of excess prescribed quantities for pharmacy and durable medical equipment (DME).

In addition to the existing legacy wastage and abuse issues within claims processes, there is now a greater need for specialized processes within payment integrity.

The return-to-normal volumes predicted for quarter three rested mostly on coronavirus utilization — with varying results across payers. There was COVID-19-related higher medical loss ratio increase for some payers — with some payers experiencing deferred care but often not at predicted levels. While other payers had higher than expected deferred care, there were also plans showing continued declines in enrollment.

The unpredictability across payments and bills resulted in operational challenges only heightened by the labor shortage. Health plans are challenged with multiple effects of this shortage — on top of enrollment declines, there are struggles with remote work, resource reallocation to support critical COVID-19 initiatives, and the resulting recruitment and retention of billing staff.

All of this amounts to operational disorder to effect more billing inaccuracies and payment errors. In addition to agility and flexing to meet seasonal shifts, another challenge lies in putting data to use to identify the aberrant providers, erroneous claims, and incorrect payments.


Elevated people, process, and technology payment integrity expertise is needed to help design a program that will be able to handle these fluctuations and resource challenges allowing organizations to step up the audit accuracy focus — with rules and query writing for a prepay focus.

The right experts leverage a pre- to post-pay approach for a proactive and preventive strategy to exponentially drive down inaccuracies and overpayments for improved recoup for payers over time. These experts can provide top-notch analytics tools and techniques that are combined with automation, machine learning, custom configuration, and manual review and intervention to analyze the claims data. The right experts deliver a brain-bot combination as they also bring the human ingenuity via skilled, experienced payment integrity specialists. Finally, the right payment integrity expertise requires robust internal business analytics solutions that depend on knowledgeable resources across IT, PI, and the SIU to maximize actionable findings.

2. Expansive state and federal regulation changes coupled with demand for transparency

The pandemic has brought swift changes in regulations and policies to ensure access to patient care. Health plans have been burdened with more and more administrative lift as well as increased regulations focused on greater transparency in billing processes — beyond the already tall order for modern-day member care and experience focus. Now these plans have to keep in step with federal government regulations while also enforcing individual states’ mandates regarding “non-essential” claims processes and review of COVID-19 related claims.

Among the many pandemic payment fallouts, this scenario is played out daily — a patient with coronavirus symptoms undergoes not just the COVID-19 test but possibly other tests to rule out respiratory problems. Confusion around payment, services, and improper coding are just a few of the factors that can then result in a surprise bill. This bill starts a long and expensive journey to correct coding and payment — at a significant loss to all parties: patient, provider, and payer. This surprise bill is today a key focus of the NSA relating to how providers and payers will communicate with individuals on hospital billing of payers and will also make the reconciliation process more complicated.

Ultimately, new government regulation, COVID-19 requirements, exceptions, and payment-related complexities have only intensified payment integrity challenges.


These experts can provide the deep domain and current understanding of regulations and rules, augmented by the requisite highly trained claims and coding expertise to optimize operations for payers. Payment integrity solution providers also have the required stringent attention to drive improved accuracy of information between provider and payer to ensure that there isn’t a post-pay audit issue associated with the par/nonpar provider in relation to new regulations around billing processes.

3. Rapid increase of telehealth billing and inaccuracies

Early in the pandemic, telehealth utilization surged as consumers and providers sought ways to safely access and deliver healthcare. At the core of COVID-19 disruption are emerging services and new medical coding and billing procedures — with telehealth at the top of the list. A significant number of health plans expanded coverage for telemedicine and telehealth services related to behavioral health, specialist visits, and primary care so people could receive care while remaining safe at home.

In April 2020, research showed that overall telehealth utilization for office visits and outpatient care was 78 times higher than in February 2020.

In addition to the patient/member-centric benefits of access to providers, telehealth also brings potential coding and payment aberrations. Case in point, there is the risk of coding of e-visit or virtual check-in claims to higher-level telehealth visits, as well as up-coding of evaluation and management (E&M) services to a higher level of service than actually rendered. Undoubtedly, the addition of telehealth will surely drive an increase to stats like yesterday’s citation of 80% of medical bills with errors, per Medical Billing Advocates of America research.


Health plans are experiencing a clear need for highly trained coding resources that can meet CMS timelines and unforeseen resource demand. The right payment integrity experts will bring rightshoring of cost-effective resources that are highly trained AHIMAs or AAPC-certified coders. This labor pool can further scale quickly and complete projects of any size with the maximum level of accuracy following a proven quality assurance process.

In conclusion

As expert problem solvers, payment integrity solution providers have the best exposure to the understanding of the nuances of the COVID-19 impact, including the regulations and how they can affect business from an end-to-end perspective.

The global reach of some of these service providers allows for rightshoring models that ensure that compliance standards are met while still providing cost and operational optimization, with the implementation of new tools, such as analytics, AI, and automation.

The healthcare industry presents a complex lifecycle of stakeholders with financial impacts and experience expectations — and payers must answer to all of them. These parties are all influencers of market position, image and, ultimately, success. With the right payment integrity approach and finely tuned focus, payers will find the exceptional service execution require to thrive in today’s environment.