Payment integrity teams are under real pressure. Medical spend keeps rising. Margins are tighter. Regulators are watching more closely. At the same time, provider relationships are getting harder to manage.
Industry reporting has been calling this out more directly. Becker’s and Fierce have both noted that payment integrity is reaching a tipping point, where traditional recovery driven approaches are creating friction without fixing root causes.
Most of that friction is not intentional. It is structural.
Where Things Go Wrong
Payment integrity programs are usually built around recovery. Find the error. Request the overpayment. Wait for the appeal. Repeat.
From the payer side, this feels responsible. From the provider side, it often feels adversarial.
Becker’s has reported on growing provider frustration with payment audits, appeals, and post pay recoveries, especially when requests are high volume and poorly contextualized. Providers spend time chasing contract language and clinical documentation just to respond. Trust erodes.
And none of this improves how claims get paid tomorrow.
Accuracy Too Late Is Still a Problem
Recovering dollars after the fact helps financially, but it does not improve daily operations.
Many payment errors are not fraud or abuse. They come from mismatches between contracts, policies, and how claims are adjudicated in practice. Manual processes make those mismatches hard to catch early.
Fierce Healthcare has highlighted how payers continue to rely on retrospective review even as claims volume and complexity outpace what manual teams can realistically manage.
By the time a recovery happens, operations teams are overloaded, providers are frustrated, and members feel the downstream impact.
Shifting the Focus Upstream
Some health plans are starting to shift where accuracy happens.
Instead of relying almost entirely on post pay recovery, they focus on preventing errors earlier by:
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Validating contract terms before and during adjudication
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Ensuring required documentation is present upfront
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Flagging claims that are likely to turn into disputes
Industry coverage increasingly points to pre pay accuracy and smarter validation as the path forward, not just bigger audit teams.
Where AI Actually Helps
AI matters here, but only when it is applied to real operational work.
The biggest gains come from automating tasks payment integrity teams already struggle with:
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Extracting and structuring contract language
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Comparing claims to contract and policy rules
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Assembling appeal and dispute packets automatically
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Identifying patterns that signal future disputes
This is not about black box decisions. In regulated environments, explainability and auditability matter.
What Changes When Payments Are Right the First Time
When accuracy improves earlier in the workflow, a few things happen quickly.
Payment integrity teams spend less time on cleanup. Providers see fewer recovery requests and faster resolution when issues do arise. Appeals volumes drop. Conversations change.
Becker’s reporting on payer provider dynamics consistently points to transparency and predictability as key drivers of better relationships.
A More Sustainable Model
Payment integrity does not have to be a constant source of friction.
With an operating layer that sits on top of existing claims and policy systems, payers can improve accuracy without replacing core platforms. The goal is simple. Fewer errors. Less manual work. Better relationships.
If you want to explore how payers are improving payment accuracy while reducing provider abrasion, get in touch.
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