Payment integrity: 5 ways stewardship is taking shape

Health plans are under increasing pressure to control costs, navigate growing oversight, and deliver greater transparency. In this landscape, payment integrity has become more than a safeguard — it’s an example of stewardship, strengthening performance through accuracy, accountability, and trust across the claim payment lifecycle.

While retrospective claim payment review and recovery will always play a role, stewardship in payment integrity is increasingly about proactive partnership — preventing overpayments before they occur, reducing friction with providers, and creating a seamless experience for everyone involved.

“Payment integrity is evolving into stewardship,” said Aaron Browder, President of Carelon Payment Integrity Solutions. “That means plans and their PI partners must be fully aligned. The partnership will only work if both are working together toward common goals and objectives.”

These five examples show how stewardship is taking shape across payment integrity — revealing where the work is heading and how collaboration is redefining success.

 

1. AI enhances accuracy and insight

 

Artificial intelligence continues to shape healthcare, and payment integrity is no exception. Continued investment in tools that support speed, accuracy, and scale is becoming more common — not to replace people, but to help them work smarter. This progress is already taking shape in several key areas:

• Automating unstructured data: Natural language processing can help scan provider notes, clinical records, and member questionnaires to identify potential documentation gaps and errors earlier in the process. This reduces rework, accelerates reviews, and improves payment integrity outcomes.
• Real-time claim scoring: Technology and advanced analytics can assign risk scores to claims, allowing teams to prioritize those that may involve another responsible payer and gauge the likelihood of success in pursuing the claim payment responsibility.
• Continuous model learning: Postpay insights can inform prepay models in near real time, creating a feedback loop that helps identify anomalies earlier and strengthens prepay accuracy.

As plans adopt healthcare AI responsibly, the focus remains on attaining balance — using the new technologies to support people with faster, more accurate data, and broader, deeper insights that advance the goals of payment integrity.
 

2. Oversight strengthens readiness and resilience

Regulations continue to evolve, and health plans are adapting by building stronger governance, compliance, and analytic frameworks that help them respond to change with confidence. The focus is on readiness, defensibility, and continuous improvement, helping payment integrity programs meet today’s standards and adapt to tomorrow’s challenges. This focus on internal oversight is materializing in several ways:

• Payment accuracy: Plans are expanding proactive, data-driven strategies to detect duplicates and potential errors earlier in the claim payment process, strengthening prevention, not just recovery.
• Fraud, waste, and abuse (FWA) detection: Increasing FWA costs are driving PI programs to use technology more broadly for automated claims auditing as well as employing predictive analytics to identify potential fraud, waste, and abuse before payments are made.
• Payer responsibility and coordination: PI programs are enhancing the establishment of responsible payer order faster and more accurately by improving the data they use as well as how they use it.

By practicing good stewardship through payment integrity, health plans are reducing risk, improving transparency, and positioning their payment integrity programs to evolve confidently as regulations change.
 

3. Interoperability connects data and collaboration

While true interoperability remains a long-term goal, momentum is building. Many health plans are enhancing existing systems to make data more connected, accessible, and actionable. For payment integrity teams, better data flow enables greater accuracy, fewer manual touchpoints, and faster, more consistent outcomes. These investments are advancing interoperability through:

• API adoption: Plans are expanding connections that bring clinical and administrative data directly into payment integrity systems, enabling faster, more informed payment determinations.
• Cross-payer and care provider collaboration: Shared data platforms are enabling more efficient identification of potential fraud, waste, and abuse while improving coordination and visibility across payer and provider systems.
• Holistic data views: Integrated data is creating a clearer picture of each claim, supporting more accurate, consistent, and fair payment outcomes.

Each advancement in data connectivity strengthens payment integrity operations, improving accuracy, accountability, and collaboration across the healthcare ecosystem.
 

4. Automation and human proficiency work in balance

The future of payment integrity isn’t purely digital — it’s hybrid. Healthcare automation continues to take on repetitive, rules-based work, while human insight remains essential for complex, high-impact payment determinations. Together they create efficiency, consistency, and scale without sacrificing accuracy or empathy. This balance is coming to life through:

• Robotic process automation (RPA): Many plans are expanding their use of RPA to handle manual payment reviews and data matching, improving consistency and turnaround times across large claim volumes.
• Human-AI collaboration: Advanced technology helps identify straightforward payment scenarios so specialists can focus on complex, high-value determinations.
• Automated workflows: Standardized outreach and integrated systems help reduce variability and improve coordination with care providers.

When automation works hand in hand with human expertise, payment integrity programs can scale effectively while maintaining accuracy, fairness, and trust — a true reflection of stewardship in action.
 

5. Expertise combined with empathy drives long-term success

Experience is taking on new importance as health plans intensify their focus on building stronger, more sustainable relationships with members and providers — recognizing that success depends not only on performance, but also on how it is achieved.

Programs that accomplish high levels of claim payment accuracy with minimal friction or unnecessary administrative burden are playing an integral role in lowering costs by supporting efficiency, improving collaboration, reducing rework, and leading to better overall outcomes. This growing focus is changing how programs are designed and measured to strengthen outcomes by:

• Reducing disruption: Programs built with empathy for provider and member needs improve clarity, minimize avoidable errors, and foster faster resolutions.
• Improving communication: Clear, timely communication resolves questions quickly and supports smoother collaboration across teams and stakeholders.
• Building trust: Consistent, transparent processes demonstrate fairness and reliability, strengthening confidence and long-term partnerships.

By making experience part of the performance conversation, health plans are strengthening relationships, improving program effectiveness, and advancing stewardship across the claim payment lifecycle.
 

Looking ahead

Payment integrity continues to evolve — advancing accuracy, transparency, and collaboration to strengthen trust across the claim payment lifecycle. The next chapter won’t be defined by a single technology or regulation, but by how effectively health plans collaborate — within their own teams and across the industry — to ensure every payment is accurate, appropriate, and responsibly made.

As a trusted partner, Carelon helps health plans advance this evolution — putting stewardship into practice through people, processes, and platforms that strengthen integrity, reduce abrasion, and deliver lasting value across the claim payment lifecycle.