Deliver better results with payment integrity program management

In today’s healthcare landscape, a cohesive, high-performing payment integrity (PI) program is essential to delivering results. Often, PI programs operate in a siloed, fragmented environment — missing cost-saving opportunities and limiting measurable performance. Many health plans feel this strain and are seeking expert support. A comprehensive, end-to-end PI program can ease that burden — driving efficiency, optimizing outcomes, and delivering measurable results.

 

The role of program management

 

Through our PI program management approach, we partner with health plans to establish a cohesive framework and big picture view. From there, we tailor an end-to-end program uniquely suited to individual plan needs and designed to get results.

As program manager, we serve as a health plan’s trusted advisor — bringing together the best capabilities in the market to seamlessly manage every engagement. Clients benefit from a single, dedicated point of contact who ensures clarity, accountability, and results. We begin by gaining a deep understanding of each client’s unique challenges and pain points, then chart a path forward to achieve measurable success. 

 

We meet clients where they are

 

Every health plan is at a different stage in their PI journey. That’s why we start by conducting a PI assessment to agnostically evaluate current structures, workflows, technology, and reporting capabilities. We then benchmark against industry best practices and identify the most impactful opportunities for improvement.

The resulting report delivers clear, actionable insights: it highlights operational gaps, identifies areas for optimization, and provides a prioritized roadmap for both short-term wins and long-term transformation. While some initiatives can be executed independently by the plan, all contribute to building a stronger, more effective PI program and achieving measurable results. 

 

A handshake, not a handoff

 

As PI program managers, we bring solutions that offer end-to-end claim payment lifecycle coverage, such as:

• Other Party Liability, with Coordination of Benefits and Subrogation.
• Provider Audit, with Fraud, Waste, and Abuse Insights and Clinical Audit.
• Claims Audit, with Data Mining.
• Other Services, including Provider Overpayment Recovery, Credit Balance Audit, and Medicare Secondary Payer Premium Recovery.

Of course, solutions are only as good as the oversight that comes with them. Many plans work with multiple vendors across different PI functions. Without coordinated oversight, vendor efforts can overlap or even conflict, leading to inflated costs. That’s why our program management framework:

• Establishes clear governance and communication protocols.
• Defines non-overlapping scopes for each vendor.
• Sets measurable performance targets and conducts ongoing scorecard reviews.
• Ensures vendors operate within the same data, reporting, and analytics framework.

When you have a unified view of total program performance, it’s possible to see the real picture and have more peace of mind.

 

Data-driven decision making

 

Central to our approach is how we use data and analytics. Through our Carelon Data Platform, we consolidate insights across all PI activities into a single reporting environment. You gain:

• Dashboards with customizable views.
• Real-time performance tracking.
• Savings attribution clarity — knowing exactly which interventions are driving results.
• The ability to model the impact of new initiatives before implementation.

This level of transparency not only improves decision-making but also builds internal and provider trust in your PI program, high-value work.

 

Delivering measurable outcomes

 

When PI program management is done right, the results are compelling and clear. They include:

• Higher total program savings through coordinated strategies that reduce vendor spend.
• Improved administrative efficiency, freeing staff to focus on higher-value tasks.
• Stronger provider relationships with less abrasion and clearer communication.

At Carelon, we bring the vision, the tools, and the expertise to make your PI program not just operationally sound, but a true driver of financial and operational excellence.

Whatever your PI goals, our role is to navigate the complexities, orchestrate the players, and deliver results. The future of Payment Integrity is coordinated, data-driven, and strategically managed. Let’s build it together.

PI isn’t about more vendors — it's about a smarter approach. With the right program management, health plans can turn Payment Integrity into a strategic driver of financial performance and operational excellence.