Health plan executives are balancing competing priorities: controlling costs, improving accuracy, and maintaining stronger provider relationships, all while keeping claims moving at speed.
We see many organizations still relying on a familiar model: pay claims quickly and recover errors later. While this approach prioritizes speed, it is becoming harder to sustain. Recovery is costly, often incomplete and can strain provider relationships.
As financial and operational pressures increase, leading health plans are shifting payment integrity upstream to prevent errors before they occur. This shift is more than operational. It is a practical way to improve cost control, efficiency and provider engagement.
Why payment integrity is moving upstream
Post-payment recovery, often referred to as “pay and chase,” has long been the default. It accepts a level of payment leakage as the cost of doing business.
However, recovery efforts rarely deliver full value. Health plans cannot recover all improper payments, and the effort required consumes time and resources that could be better used elsewhere.
Prepay changes the equation by focusing on cost avoidance rather than cost recovery. For CIOs, COOs and CFOs, this represents a shift from reactive correction to proactive control, paying claims accurately the first time while protecting operational efficiency and financial performance.
Precision over volume: A critical mindset shift
A common misconception about prepay is that more controls will drive better results. In practice, success depends on precision. High-performing health plans focus on claims that drive the greatest impact rather than moving all activities upstream. This targeted approach improves savings outcomes, reduces unnecessary reviews and minimizes disruption for providers. A disciplined prepay strategy prioritizes:
- High-value claim categories with the greatest savings potential
- Data-driven claim selection to improve accuracy and hit rates
- Phased implementation to ensure operational stability
For executives, this means aligning prepay initiatives with measurable financial and operational outcomes rather than volume.
Operational readiness: Enabling speed at scale
Shifting to prepay introduces new operational demands. Without the right foundation, claims processing can slow and provider friction can increase. Common challenges include:
- Limited real-time integration with claims systems
- Insufficient automation to support rapid decision-making
- Unrealistic expectations about the pace and scale of implementation
Leading health plans address these challenges with a structured, phased approach. They align technology, workflows and contractual requirements before expanding prepay programs. Clear service-level agreements and disciplined execution help maintain claims flow while introducing stronger controls.
AI’s role: Scaling insight and efficiency
Artificial intelligence is accelerating payment integrity, but it is not a replacement for sound processes. It is an enabler. When applied effectively, AI helps health plans:
- Identify high-risk claims with greater accuracy
- Analyze large volumes of claims data in real time
- Streamline complex reviews, including medical record analysis
For example, manual medical record reviews can take hours per claim. AI can significantly reduce review time, allowing teams to focus on decision-making and quality.
Solutions like CGI ProperPay combine AI, machine learning and natural language processing with deep healthcare expertise to help ensure claims are routed to the right reviewers at the right time. This targeted approach improves accuracy while maintaining speed and operational efficiency.
However, AI depends on a strong data foundation. Fragmented or inconsistent data limits its effectiveness. For CIOs, this reinforces a clear priority: invest in data quality and integration to unlock measurable value.
Reducing provider abrasion through transparency and trust
Provider abrasion remains one of the most significant risks in prepay. Leaders must balance stronger controls with a seamless provider experience. The most effective organizations focus on three principles: communication, collaboration and transparency. In practice, this includes:
- Communicating audit approaches and expectations upfront
- Sharing insights and trends with providers on a regular basis
- Delivering timely, transparent feedback on claim decisions
Minimizing unnecessary documentation requests and maintaining clear turnaround times also play a critical role in reducing friction. When providers understand the process and see it applied consistently, trust improves. That trust is essential for long-term success.
What success looks like in 12 to 24 months
When prepay is implemented with discipline and focus, the results are measurable. Health plans can expect:
- Faster review cycles driven by automation and AI
- Reduced administrative costs through elimination of rework
- Increased cost avoidance by preventing improper payments
- Improved claims accuracy and consistency
- Stronger, more collaborative provider relationships
In addition, resources previously dedicated to recovery efforts can be reallocated to strategic priorities that drive growth and innovation.
A strategic opportunity for health plan leaders
The shift to prepay is about making better decisions sooner. For leaders, it represents an opportunity to align technology, operations and financial performance around a more proactive model of payment integrity.
The path forward requires focus, strong data foundations and a commitment to provider partnership. The outcome is clear: The best claim is not the one you recover later. It is the one you pay correctly the first time.
Data, automation and AI are already accelerating the shift of payment integrity upstream. Successfully navigating this transition requires a careful balance of accuracy, efficiency, and provider experience.
If you’re exploring this area, contact with us to discuss what’s working, what’s evolving, and how organizations are approaching it.
About these authors
Karen Ballard
Director Consulting Expert
As Director Consulting Expert, Karen Ballard manages the CGI ProperPay payment integrity platform. With a nearly 20-year career in the health payer space, Karen possesses a deep knowledge of claims processing, product management, payment integrity, and the Blue payer dynamic. Before joining CGI, Karen held ...
David Ott
Director, Consulting Expert
David Ott has over 28 years of experience in the financial and healthcare services industries. David has provided guidance and direction to department leaders and teams that support a variety of functions, including business development, claims processing, global project management and quality practices.
