Why is payment integrity getting so much attention?
Payment integrity is getting more attention in employer health plans, and for good reason. At its core, payment integrity is about making sure claims are paid accurately — to the right provider, in the right amount, and under the right plan and contract terms — while improper payments are prevented, identified, corrected or recovered when they occur. For employers sponsoring self-funded health plans, that matters because claims accuracy affects plan cost, plan performance, vendor oversight and overall governance.
It is also getting more attention because the tools are changing. Analytics are getting smarter, and AI-enabled tools are helping uncover patterns and payment issues that older methods often missed. That creates new opportunities, but it also creates more complexity. “Payment integrity” is now being used to describe a wide range of services that do not all serve the same purpose.
Understanding the differences between services matters. Carrier and Third-Party Administrator payment integrity programs, independent third-party payment integrity vendors, and electronic claims audits are often discussed as if they were interchangeable. They are not. And when employers treat them that way, it can lead to unrealistic expectations, overlapping efforts and too much focus on projected savings without enough clarity on what those numbers actually represent.
Understanding the differences
Carrier and TPA payment integrity programs are an important part of the current landscape. Many administrators now offer pre-payment and post-payment programs designed to catch improper payments and improve claims accuracy. In many cases, these arrangements are tied to shared-savings or recovery-based fees, so it’s important to know how savings are defined, what triggers the fee and whether the incentives support both prevention and correction efforts.
Independent third-party payment integrity and fraud, waste and abuse vendors are also drawing attention. Many offer pre-payment or post-payment solutions, monthly reviews, audit-style evaluations, or broader payment integrity assessments. Some bring strong technology, and many are using AI and analytics in ways that can surface patterns older approaches may miss, such as billing and coding issues across multiple claims or issues that are not captured in carriers’ payment integrity reviews. That can be valuable, but employers should be realistic about where these vendors fit in practice. Carrier operating models and ASO agreement terms often limit what outside parties can do on a pre-payment basis or in ongoing monthly post-payment review. In many cases, that means an independent third party may function more as a targeted review resource or as electronic audit support than as a fully integrated, ongoing payment integrity solution.
Electronic claims audits serve a different purpose. Rather than focusing only on identifying or recovering improper payments, they help employers assess whether claims are being paid accurately, whether plan administration is functioning as intended, and whether recurring issues are being addressed. Because this approach reviews the full claims population within scope, rather than just a sample, it can provide a more complete view of payment integrity and overall claims performance. This gives employers the opportunity to validate how well existing payment integrity programs are actually working, identify recurring administrative or contractual issues, and build a clearer basis for remediation, recovery and ongoing oversight. In many cases, ASO agreements between employers and carriers also preclude audits from being performed on a contingency or shared-savings basis. That means these reviews are often structured as fee-for-service engagements, with the emphasis on documented findings, remediation, corrective action plans, and stronger accountability going forward.
Those audits should be complemented by a clear understanding of the payment integrity programs already built into the employer’s carrier or TPA arrangement, including how savings are calculated, how fees are structured and how results are monitored over time. Independent third-party payment integrity vendors may still have a role in some situations, but that role is often narrower in practice because carrier restrictions can limit how those vendors operate. For that reason, we see regular independent fiduciary due diligence claims audits as the clearest and most reliable foundation for broader independent payment integrity oversight.
Why this matters to employers
For employers, the key question is not whether payment integrity matters. It does. The more useful question is what kind of oversight will help them understand whether claims are being paid correctly, whether existing payment integrity arrangements are working as intended and whether identified issues are actually being corrected.
That matters because the different approaches described above are designed to do different jobs. Carrier and TPA programs may support day-to-day payment controls. Independent third-party vendors may add targeted analytics or review capability in certain circumstances. Independent fiduciary due diligence claims audits provide something different: a broader view of claims accuracy, administrative performance, recurring issues and corrective action.
To make sense of the growing number of payment integrity offerings, think less about any one solution and more about overall oversight. Here are some guidelines for building a comprehensive payment integrity strategy:
Start with regular independent fiduciary due diligence claims audits. In our view, these audits should be part of the employer’s regular oversight framework, typically every two to three years. They provide an independent way to assess claims accuracy, identify recurring issues, document findings and support remediation over time.
Then make sure you understand the carrier or TPA program already in place. Employers should know what payment integrity activities are already embedded in their administrative arrangement, how those programs work, how savings are calculated, what fees are attached and what actually triggers payment. Shared-savings and recovery-based arrangements deserve especially close review.
Be clear about what results actually mean. Dollars identified, validated, recovered, corrected, and avoided are not the same thing and they should not be treated as though they are. Employers should ask for precision around how results are measured and reported.
Understand the contractual and operational limits. ASO agreement terms, carrier operating models and data access rules can shape what is realistically possible. Those constraints may limit outside pre-payment review, ongoing monthly post-payment review or contingency-based audit arrangements.
Focus on follow-through, not just identification. The real value often lies not in finding an issue, but in confirming that it is addressed, root causes are corrected and repeat problems are monitored over time. Employers should be clear about who owns remediation, what corrective action process will be used and how improvement will be tracked.
Use independent third-party support selectively. Some vendors may bring useful analytics or targeted review capabilities, but employers should evaluate that support based on what is actually feasible within the carrier environment, not just what is promised in theory.
Better data, stronger analytics and improved technology are creating new opportunities to improve claims accuracy and plan performance. Payment integrity is becoming a bigger part of the employer health conversation, and that is probably a good thing if employers use that momentum to strengthen their overall oversight strategy rather than simply add another solution.
