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Vital steps to optimizing payment integrity

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Speaker 1: Payers in today's market are facing financial challenges. One major factor is the lost funds due to improperly paid claims. If you're trying to recoup those funds through a post-payment recovery model, you're using an outdated and ineffective approach. By implementing a payment integrity strategy that focuses on prepayments and cost avoidance, you could see significant savings, potentially reducing both administrative and medical spend costs.

Speaker 2: Payment integrity is important to payers because it's all about claims accuracy, paying the right claim at the right time for an accurate dollar amount. It drives medical cost savings within the organization and it's really become a strategic asset within our payers' portfolios. When you think about the evolution of payment integrity, for a long time it was a nice-to-have asset. It was something that payers did. Today, they really have to count on payment integrity to drive those medical cost savings, making their products more affordable to the market.

One of the complexities I see in payers today is, oftentimes, their payment integrity assets are spread across the company and there's really no one strategy or one vision for a clear payment integrity program, and that's a big challenge. Optum is uniquely positioned in the marketplace and that we do cover the entire spectrum of payment integrity within our business whether it be software-based solutions around claims editing or pricing, prepaid programs, predictive models, subrogation, postpaid programs.

We also have our consulting group that helps to identify areas that might be underserved by a payer, so we can drive higher value within the marketplace. A good payment integrity program will maximize recovery by starting really pre-claim and the EDI stream and going all the way through the adjudication process, and ultimately also post payment analysis of the claims that have gone out the door to ensure that your payment integrity program hits the entire ecosystem.

Setting payment integrity goals within a health plan is very important. Just like any other program, people want to know when they win, when they succeed, and setting a goal each year around a payment integrity target helps people to get there. It's also important to understand that payment integrity isn't a one-time thing, it's something that lives and evolves year after year. By creating payment integrity as a strategic asset within your health plan, you can save an incremental 2 to 4% to your medical spend.

To see changes in your payment integrity next year, you really need to start now defining your strategy and implementing your solution. Partnering with a company like Optum, we can help you achieve those results.

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Steve Yurjevich, vice president and general manager, Optum Payment Integrity, discusses key factors to consider when exploring a comprehensive payment integrity strategy. Get ahead of the curve and competition by identifying opportunities to uncover additional savings.