Diagnostic Approach For Payment Integrity

In an era of shifting risk pools, evolving member needs, and rising medical costs, health plans are navigating a more complex operating environment than ever before. While these pressures are significant, they also create opportunities for organizations that can quickly identify, prioritize, and act on areas of improvement.

One proven way to uncover these opportunities is through a diagnostic payment integrity (PI) approach — a method that gives plans a clear, data-driven view of where inefficiencies exist, what’s driving them, and how to address them for measurable results.

What we mean by “diagnostic”

A diagnostic, or consultative approach goes beyond measuring how much you’re recovering in overpayments or preventing through edits. It takes a step back to ask:

Where in our claims process are value leaks occurring?
Which workflows are slowing us down or limiting our ability to validate leads for recoveries?
How are technology, governance, and vendor arrangements supporting — or constraining — our outcomes?

Carelon’s PI diagnostic framework addresses these questions through a structured PI program assessment. This assessment evaluates four core areas:

Structure: How governance, departmental integration, and resource allocation impact PI effectiveness.
Workflow: Where manual processes, outdated rules, or gaps in capabilities create inefficiencies.
Technology: How analytics, automation, AI, and reporting tools are being leveraged (or not) to maximize detection and prevention.
Value and reporting: The ability to track, quantify, and communicate savings across the organization in a timely and actionable way.

The payoff for plans

This approach pays off in multiple ways — some immediate, others long-term:

Clear savings roadmap: By mapping your current operations against industry-leading practices, we can help you see exactly where the biggest opportunities lie.

Better resource alignment: Diagnostic insights highlight how internal teams can work more efficiently to increase processing volume and accuracy.

Faster, smarter decision-making: With flexible, on-demand reporting, leaders can act quickly when unexpected occurrences happen, or cost drivers change. Instead of relying on quarterly retrospectives, you gain near real-time visibility into emerging issues and can capitalize on longer-term trends.

Sustained program growth: The assessment doesn’t just uncover gaps — it informs a prioritized, phased roadmap for PI progress. This ensures that as billing complexities increase, our payment integrity program continues to meet the challenge.

From discovery to action

The value of a diagnostic approach lies in its ability to turn insight into action. Carelon’s process moves from evaluation to measurable results through five steps:

Assess: Conduct a PI program insights workshop and stakeholder interviews to build a clear picture of current-state capabilities.
Analyze: Review historical claims data to identify both cost avoidance and recovery opportunities.
Align: Facilitate value workshops to confirm priorities and ensure alignment with enterprise strategy.
Activate: Implement quick wins first — such as optimizing existing concepts or introducing targeted analytics — while planning for longer-term transformation.
Advance: Continuously refine the program with new data, emerging technology, and feedback loops.

Why this matters now

In a competitive market, operational efficiency and financial performance go hand-in-hand. A diagnostic PI approach gives you:

Clarity: A comprehensive understanding of where you stand and where to focus.
Confidence: Data-driven insights that back investment decisions and strategic pivots.
Capability: A roadmap for building the structures, workflows, and technology needed for long-term success.

Instead of reacting to cost pressures with one-off fixes, you create a scalable, repeatable model for continuous improvement — turning payment integrity into a strategic asset rather than a reactive function.

The bottom line

A diagnostic payment integrity approach pays off by giving health plans the insight they need to act decisively, the structure to execute efficiently, and the foresight to stay ahead of challenges. With Carelon’s consultative framework, you can transform payment integrity from a back-office process into a strategic driver of enterprise value.