The stakes have never been higher
Healthcare costs are rising at a pace that outstrips inflation and GDP growth. According to PwC’s Health Research Institute, medical costs in the group and individual markets are projected to increase by seven percent in 2025. At the same time, administrative complexity and claim volume are surging, putting unprecedented pressure on health plans to contain costs, ensure compliance and maintain provider relationships.
In this environment, payment integrity is no longer a back-office function — it’s a strategic necessity.
But not all payment integrity strategies are created equal.
The industry is at a crossroads: Should payers continue to rely on post-payment recovery, or shift investment and focus to pre-payment detection and prevention?
Why is pre-pay payment integrity important?
In our many years of experience, our clients have said that pre-pay reviews:
- Reduce administrative burdens. By catching inaccuracies early, all of the downstream extra work and expense is avoided.
- Reduce cost. Our payer clients don’t have to deal with lots of money being tied up in the “hamster wheel” of pay-and-chase models. The savings are returned to them much sooner.
- Reduce friction. In the same way that payers know the true amount of the allowed payment much sooner, providers can also receive their payments more promptly.
Building a modern pre-payment integrity program
1. Invest in innovation:
Lean on technologies that identify claims most prone to coding errors, upcoding, or policy violations — before payment is made.
2. Intelligent routing:
Route flagged claims to the right review channel — whether that’s automated editing, clinical validation review, or expert coding validation.
3. Keep experts in the loop:
AI is an enabler, not a decider. Human experts validate findings, ensure context is considered and provide defensible rationales for edits or denials.
4. Prioritize transparency:
Every edit or denial should be accompanied by clear, policy-based explanations that providers can understand and accept.
5. Measure what matters:
Track not just gross savings, but sustainability (how much is upheld), provider abrasion, and prompt-pay compliance.
With years of experience in pre-payment integrity, Zelis has developed capabilities that allow us to handle pre-pay reviews built on deep industry experience and trusted by leading health plans.
Key features include:
- Unparalleled integration with adjudication platforms. We work closely with adjudication partners, just like they are a member of our team, so that claims flow smoothly from our payer clients. This makes the whole process much easier for our clients.
- AI-in-the-loop.* At Zelis, AI supports — not replaces — our expert teams. We use cutting-edge tools to amplify human insight, not automate decisions.
- True partnership. We don’t have a one-size-fits-all rulebook. We know that each payer has a unique set of members, providers and business needs – we thus craft a customized set of PI solutions and act as a true partner to our clients.
Invest upstream for downstream success
The healthcare landscape is only getting more complex. Payers who continue to rely solely on post-payment recovery will find themselves fighting a losing battle against rising costs, provider abrasion, and regulatory risk.
The path forward is clear: Invest in pre-payment integrity to get it right the first time.
By shifting resources and focus upstream, health plans can achieve sustainable savings, improve provider relationships, and deliver on their promise to members. At Zelis, we’re ready to help you make that shift — responsibly, transparently and with the expertise you deserve.
If you want to know more, reach out to us and schedule a payment integrity strategy consult.
* Zelis exclusively employs closed-source artificial intelligence (AI) platforms to enrich its product suite, ensuring adherence to legal, ethical and industry-leading standards. All outcomes are rigorously and continuously reviewed by Zelis personnel to ensure quality and reliability
