Payment Integrity: Comprehensive Strategy Fights the Rising Cost of Care
Health care spending in the U.S. is projected to reach $4 trillion in 2020 
and will likely grow by an additional $2 trillion over the next eight years. Sadly, an estimated one-third* of that care is wasted through excessive prices, system complexity, abuse, duplicated and unnecessary treatments and more.
Also, COVID-19 trends have driven claims for testing and treatment and high-dollar inpatient stays, increasing the risk for fraud, waste and abuse.
But there is a silver lining. It’s estimated that actively intervening to stop wasted care could save up to $282 billion annually. We see evidence of that every year through our payment integrity functions. We manage care holistically from beginning to end, working closely with providers, clients and members to generate significant employer savings.
It Begins with the Member
Members have access to networks where we negotiate with providers for reduced service costs while connecting payments to the quality of patient health outcomes.
Once care is delivered, we focus on ensuring that payments are appropriate, accurate and prompt. Our payment integrity program consists of a multi-disciplinary team of health care management, network, claims, customer service, special investigations, data science and IT. The team allows us to monitor claims from the perspective of every aspect along the health care continuum.
A Sophisticated Approach to Stopping Fraud
Provider coding errors are often accidental, but sometimes may be done intentionally to gain higher reimbursement. Our sophisticated procedure code software – modeled on the Centers for Medicare & Medicaid Services, American Medical Association and other industry standard coding guidelines – is tailored specifically to our reimbursement policies. Then a secondary code auditing system identifies additional incorrectly billed services by reading claims history.
Our Special Investigations Department actively pursues aberrant providers and health care fraud schemes. With experts from the medical, insurance and federal/state law enforcement fields, the team uses artificial intelligence, predictive modeling and other analytical techniques to unearth fraudulent schemes.
We have invested heavily in payment integrity over the last four years, increasing our ability to avoid unnecessary costs by more than 300% across our company. Our enterprise payment integrity program helped customers in all five of our Plans — across all lines of business — save more than $2.35B in 2019 by ensuring appropriate payment and removing fraud, waste and abuse.
Our COVID-19 payment integrity task force monitors emerging trends and anomalies in billing. We’re actively investigating multiple scenarios that could lead to fraudulent, wasteful, abusive or inaccurate billing.
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