Lessons from the inside: Why expertise matters when it comes to payment integrity
Many payment integrity (PI) vendors overpromise. However, they often fall short of expectations because of outdated approaches that are typically rigid and lack transparency in how they generate or prioritize findings.
For health plans today, a PI vendor won’t do. It takes a PI partner with depth and years of experience as well as the insight to develop thoughtful and effective solutions.
Decades of experience
At Carelon, we’re born from one of the nation’s largest health plans. This experience has helped us develop solutions essential for long-term value. In other words, these insights aren’t just theoretical — they’re the result of real-world experiences managing billions of claims transactions and navigating complex operational environments.
Systems that learn
While managing PI across vast networks, we discovered that reactive, rules-based only systems quickly become obsolete. Delivering real results requires platforms that learn and adapt. Our answer? Introducing adaptive analytics and data mining models that evolve based on provider behavior, policy changes, and customer preferences. This approach helps your PI program recover more.
Precision in identifying overpayments
High recovery rates mean little without accuracy and provider trust. We prioritize precise, defensible findings – not just volume. Our solutions reduce appeals and operational noise by ensuring each overpayment lead is actionable and clearly backed by insight. The result: smarter savings with fewer disruptions.
Effective cost control
PI is no longer a mere compliance task or operational clean up function. When harnessed, it can act as a strategic lever and significantly improve cost control. What’s crucial is having effective solutions. Our advanced data mining, which uncovers improper payments with precision, prioritizes value and reduces provider abrasion through clinically driven, defensible insights. At the same time, our coordination of benefits (COB) improves primacy determination accuracy, managing a plan's full inventory to prevent missed opportunities. Together, these capabilities deliver smarter savings with less disruption.
Flexibility over one-size-fits-all
Due to the advantage of building our solutions within a very large sandbox, we know firsthand that in claims processing there’s no one-size-fits-all. For this reason, we’ve built scalable solutions that are modular, policy-aware, and compliance-ready — capable of adapting to your unique mix of plan types, regions, and business lines. Whether you’re a national payer or a regional health plan, we meet you where you are.
Commercial success
After decades of performing payment integrity for our largest client, we realized the potential of our solutions. Carelon PI is now bringing validated, high-impact answers to complex overpayment problems and serving a number of health plans. We’re ready to enhance your PI outcomes, too.
Ready to Transform Your PI Program?
Discover how our unique, inside-out expertise can help your plan modernize, minimize abrasion, and maximize impact. Contact us today for a free demo.