Claims processing is becoming ever more complex for payers given issues such as the need to transform healthcare plans’ business models to accommodate new markets and new lines of business; and increasing inflow of members; and, increasing regulatory mandates. Payment integrity is a potential help – in can reduce rising healthcare waste and fraud to ensure that the medical claims are paid correctly and free of wasteful and abusive practices.
Payers’ traditional pay and chase approach has resulted in provider abrasion and has limited the recovery of over-/incorrectly paid claims. Payment integrity product vendors provide solutions that analyze a claim in both the pre- and post-submission phases, using advanced analytics and data mining tools and solutions. They use patterns identified across billions of lines of claims to predict errors, helping payers make required corrections before processing claims.
In this report, we analyze 11 payment integrity solutions vendors’ capabilities and map them on the Everest Group PEAK Matrix™, a composite index of distinct metrics related to a vendor’s vision & capability and market impact. This report offers:
Vendors covered:Burgess, Change Healthcare, ClarisHealth, Cotiviti, EXL, FICO, FraudLens, HMS, IBM (Truven), LexisNexis, and Optum
This report has four key sections, each containing insights into the payment integrity solutions landscape: