Payment integrity programs have become increasingly sophisticated, bringing together more specialized capabilities, technologies and partners. But as these programs grow, they can become harder to manage. Health plans may have strong capabilities in prepay review, post-pay audit, coordination of benefits, subrogation and recovery, yet still struggle to manage them as a single, connected program.
The financial stakes remain high. According to the Centers for Medicare & Medicaid Services, the Medicare Fee-for-Service improper payment rate was 6.55% in fiscal year 2025, representing $28.83B in improper payments. CMS notes that improper payments do not necessarily indicate fraud. They can result from insufficient documentation, administrative errors or other unmet program requirements.
Yet adding another point solution will not solve the underlying problem.
The next step is to connect payment integrity activities so health plans have a clearer view of what is happening across the program and more control over how decisions are made. That visibility can help payers decide where and when to intervene, determine which resources or partners are best suited to the work and improve recoveries without adding unnecessary administrative cost. This does not mean bringing every capability in-house. It means making sure internal teams, technology and external partners are working together rather than operating in silos.
Control the program without owning every component
Health plans often rely on specialized technologies and partners to address different payment issues. That approach can bring valuable expertise, but it can also make it harder to see what is happening across the payment integrity program.
A payer may have separate systems and vendors examining the same claims at different points in the payment life cycle. Policies and supporting evidence may be stored in different places. Teams may not know what reviews have already taken place. Leadership may receive reporting from several sources without a clear view of overall program performance.
A connected payment integrity platform can bring those pieces together, giving payers a clearer view across the payment life cycle, including:
- Why a claim was selected and what evidence supports the finding
- Which policy or contract applies
- Whether the claim has already been reviewed
- Whether intervention is most appropriate before or after payment
- Which internal team or specialized partner is best positioned to act
Just as important, the payer retains the right to decide what to automate and what requires professional judgment. This allows health plans to consider recovery potential alongside the administrative cost and effort required to pursue it.
This kind of model can also work across organizations of different sizes. Smaller plans can gain automation and visibility without building large teams. Blue plans can maintain local flexibility, while large payers can better coordinate across business units, vendors and lines of business.
The goal is not to own every component. It’s to maintain control across them.
Turn fragmented information into shared knowledge
Control requires more than connecting systems. Teams need a shared understanding of the information behind payment integrity decisions. When claims data, policies, contracts, medical records and audit evidence remain scattered, reviewers spend valuable time reconstructing the context behind a claim.
One thing I’ve seen repeatedly in payment integrity is that fragmentation costs more than the time spent reviewing an individual claim. When teams and vendors cannot see what others have reviewed, the health plan also loses the opportunity to learn from those decisions and use that knowledge to prevent recurring issues. Bringing that information together makes it easier to find supporting evidence, apply policies consistently and understand how previous decisions were made.
The opportunity for automation is significant. The 2024 CAQH Index estimated that automation helps the healthcare industry avoid $222 billion in administrative costs annually and that an additional $20 billion could be saved through greater adoption of fully electronic workflows.
Artificial intelligence (AI) can contribute by summarizing medical records, locating relevant policy or contract language, identifying inconsistencies and assembling supporting evidence. That can free reviewers to spend less time gathering information and more time applying professional judgment.
But AI should not become another black box in an already fragmented environment. Health plans need to understand the information that supports an AI-assisted recommendation and trace decisions back to relevant policies and evidence.
Effective governance should make clear:
- When human review is required
- How AI performance is monitored
- How exceptions are handled
The payer remains responsible for the final decision. The point is not simply to automate more tasks. It’s to make the information reviewers need easier to find and use, without losing the transparency, evidence and oversight behind the decisions.
Create a learning loop from detection to prevention
A connected platform helps the organization learn across the payment life cycle. Prepay and post-pay should reinforce each other. Post-pay findings can reveal recurring issues that may warrant earlier intervention. Prepay results can show where policies, edits or provider guidance are working and where additional attention may be needed.
Not every issue belongs in prepay. Some can be addressed through claim edits, screening, provider education or pre-submission guidance. Others will continue to require coding validation, clinical review, medical record analysis, coordination of benefits, subrogation or recovery.
The question is whether the organization uses what it learns from each outcome to determine where to intervene to have the greatest impact.
That requires visibility across findings and results. Payment integrity leaders need to understand where issues originate, which providers or claim types are driving findings, where recoveries are delayed and which recurring issues may warrant a different response. External partners should be part of that visibility. A shared view of claims under review, evidence and case status can help payers and vendors identify potential overlap earlier, resolve delays and improve accountability.
Over time, the program can do more than detect and recover improper payments. What it learns can help improve where, when and how the health plan intervenes.
Modernize with a clear direction
Health plans do not need to transform the entire payment integrity environment at once. One organization may start by standardizing workflows and improving vendor visibility.
Another may centralize policies and evidence. Others may prioritize connecting prepay and post-pay or introducing AI-assisted review.
Where a health plan starts will depend on its current environment. What matters is that each step improves its ability to see across the program, make informed decisions and learn from the results.
Our perspective comes from more than 30 years of working with healthcare insurers and providers on claim billing and payment accuracy. Through CGI ProperPay and related payment integrity expertise, our clients have recovered more than $3 billion in improperly paid medical claims. Our medical claims payment integrity services have achieved audit accuracy above 99%, and an audit uphold rate above 96%.
We’re also seeing how AI-assisted capabilities can improve efficiency when applied within a governed payment integrity process. AVA, the AI-powered audit assistant within CGI ProperPay, has demonstrated productivity gains of up to 500%, process efficiency improvements of up to 25% and a minimum 97% accuracy for AI outcomes.
These results show that technology works best when it's part of a connected program, with clear governance, evidence and accountability around how it’s used. The same thinking can extend to how health plans work with providers. When health plans explain findings clearly, share evidence earlier and educate providers sooner, they can address issues earlier and build a more transparent relationship around payment integrity.
In the final blog in this series, we’ll explore how transparency, evidence and earlier intervention can help move payer-provider relationships from control toward collaboration.
If you’re looking to bring greater visibility and control over your payment integrity program, reach out to me to discuss how CGI can help.
About this author
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 ...
