As a result of the increasing complexity of the health plan environment, coordination of payments to multiple parties and a wide range of government and private health plans remains a challenge. Payment Integrity solutions are reducing the rising healthcare waste and fraud to ensure that claims are paid correctly, free of leakages. Using advanced analytics and data mining, patterns are identified across billions of lines of claims to predict errors in claims, thereby helping firms to reduce waste and focus on value-based care for patients.
We see broadly three types of engagement models in the Payment Integrity space:
- Business Process as a Service: Service provider offers Healthcare Payment Integrity to client as a service via a combination of platform (either proprietary or white labelled) and managed operations
- Platform License: Providers license the software to an enterprise who then manage the operation
- Software as a Service: Payment Integrity platform is offered on a SaaS model. The platform can be hosted on customer’s environment or on cloud. The engagement is based on an outcome-based pricing e.g., based on % of validated overpayments of recovery Per Member Per Month along with Fixed annual hosting price (if applicable)