Insights

Vendor consolidation in the payment integrity market is reshaping how service, innovation, and attention are delivered—often to the detriment of state and regional health plans. This insight outlines the hidden costs of being deprioritized by a large PI vendor, the warning signs that your post-payment audit partner isn’t giving you the attention you deserve, and strategies regional plans can use to regain transparency, accountability, and performance in a shifting PI landscape.

Penstock is using AI and machine learning to accelerate how new payment integrity concepts are discovered, validated, and deployed. In this Q&A;, President Steve Palma explains how AI identifies subtle trends in claims data, detects nuanced anomalies, enhances concept precision, and strengthens prevention strategies. Learn how Penstock blends AI-driven analysis with human clinical expertise—and why agentic AI is opening new possibilities for data quality, audit support, and end-to-end payment accuracy.

Selecting the right payment integrity partner isn’t about choosing the biggest firm or the lowest price—it’s about finding balance. This insight explains why large PI vendors can fall short on flexibility, personalization, and transparency, and why emerging and mid-size partners often deliver the agility, innovation, and hands-on support health plans need. You’ll learn the key criteria for evaluating a PI partner and how to identify a solution that’s “just right” for your organization.

Pharmaceutical reporting mismatches can lead to major reimbursement errors, inappropriate payments, and financial strain for health plans. This insight explains why mismatches occur—from coding limitations to diagnosis gaps—illustrated through real-world examples like GLP-1 utilization. Health plans will learn the key drivers behind reporting errors, the risks within retail pharmacy claims, and actionable strategies to detect and prevent discrepancies through cross-claim validation, utilization management, and data-driven oversight.

Accurate ICD coding is foundational to payment integrity. This guide explains how coding errors distort clinical data, inflate costs, increase patient and provider burden, and lead to significant overpayments and underpayments across the healthcare system. Providers and payers will learn the scientific basis of ICD coding, the financial implications of errors, and best practices for documentation, code selection, and understanding clinical interrelationships to ensure accuracy and reduce leakage.

New York’s HCRA taxes increased sharply in 2020—even though elective procedures plummeted and Medicaid enrollment rose—because the tax code is so complex that payors and providers routinely misapply it. This article explores why HCRA revenue keeps climbing and why the system urgently needs reform.