The benefits of taking a clear-eyed look at Payment Integrity Programs

Healthcare costs continue to rise. Utilization is increasing. And payment integrity programs are under growing pressure to deliver stronger results without increasing care provider abrasion or compliance risk.

For many health plans, the challenge isn’t understanding the importance of payment integrity. It’s knowing whether their current program is truly performing and where improvement is possible.

That’s where evaluation matters.

Before adding new tools, adjusting workflows, or considering a vendor change, plans benefit from taking a clear-eyed look at where they stand today. At Carelon, we think of this as establishing a clear performance baseline — facing the facts to gain clarity and direction.
 

Why assessment comes first

Payment integrity programs often evolve over time. What begins as a focused effort to recover dollars or prevent errors can grow into a complex mix of workflows, analytics, vendors, and manual processes. As complexity increases, it becomes harder to answer fundamental questions:

• Which activities are delivering meaningful value?
• Where are inefficiencies, gaps, or unnecessary friction occurring?
• How do current results compare to what’s possible in today’s environment?
• Are financial goals being balanced with operational and care provider impact?

Without a structured way to evaluate performance, plans may make incremental changes without addressing root causes or delay decisions altogether because the path forward feels unclear.
 

What it means to evaluate performance

A meaningful payment integrity assessment goes beyond surface-level metrics. It looks holistically at how a program is designed, operated, and governed.

Carelon’s payment integrity leaders help plans examine multiple dimensions of performance, including program maturity, workflow efficiency, data and reporting capabilities, compliance alignment, and care provider impact. Viewed together, these elements provide a clearer picture of what’s working and where opportunity exists.

Just as important, assessment is not about assigning grades or prescribing one-size-fits-all solutions. It’s about helping plans understand their current state so they can make informed decisions about what comes next.
 

Benchmarking against what’s possible

Evaluation becomes even more powerful when paired with benchmarking. Many plans assess performance relative to past results, but that perspective doesn’t always reveal what could be improved — especially in a market shaped by consolidation, evolving regulations, and advancing analytics.

With decades of experience operating and supporting payment integrity programs, Carelon brings insight into how plans across the industry approach similar challenges. Benchmarking helps expand what’s visible, allowing plans to compare current capabilities against broader practices and emerging approaches.
 

Clarity before change

Understanding a performance baseline doesn’t require immediate action. For some plans, assessment confirms they’re on the right path. For others, it highlights opportunities to refine workflows, strengthen reporting, or rethink how expertise and technology are applied.

Carelon’s consultative approach is grounded in meeting plans where they are — offering transparency, flexibility, and partnership rather than a predetermined end state. The result is a practical roadmap shaped by a plan’s goals, constraints, and readiness, not by a sales agenda.

As healthcare pressures continue to mount, payment integrity remains a critical lever for financial performance, operational efficiency, and care provider trust. But progress starts with clarity.

Sometimes the most important step forward is simply taking an honest look at your current payment integrity performance.