Article Summary: A stagnant payment integrity program can quietly erode accuracy, increase abrasion, and leave major recoveries undiscovered. This insight outlines the hidden warning signs—rising provider friction, growing manual workload, and vendors who only catch low-value issues—and explains what a high-attention, auditor-led PI partner should deliver to help plans recover more, improve processes, and reduce long-term leakage.

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For health plans, claim payment integrity (PI) isn’t just a back-office function — it has a direct impact on financial performance, provider relationships, member satisfaction, and operational efficiency. But today, many plans are realizing a hard truth: the PI partner they started with isn’t the partner they need now.

If you’re starting to wonder whether your PI program has stalled out, here are three hidden warning signs that it may not be keeping pace with your needs.

1. Provider abrasion is rising — and you’re the one feeling the heat

Nothing erodes provider trust faster than duplicate audits, confusing outreach, or unexplained findings. If your PI vendor is contributing to, rather than preventing, abrasion, that’s a red flag.

Common symptoms include:

• Vendors stepping on each other’s audits

• Conflicting or unclear documentation

• A surge in complaints, escalations, or appeals

• Providers feeling “attacked”  

A strong PI partner takes ownership of this. They coordinate, communicate clearly, avoid redundant disruptions, and help educate providers with defensible, clinically sound guidance. If you’re doing the smoothing-over while your vendor is creating friction, it’s time to reassess.

2. You’re doing more manual work than your PI partner is

Your PI partner should make your life easier — not add unnecessary workload to your already stretched team. But many plans still find themselves:

• Chasing down explanations

• Manually reconciling findings

• Waiting days for answers to simple questions

• Re-running data to double-check vendor accuracy

• Navigating black-box processes with minimal transparency

This isn’t how PI should work.

A good PI partner provides clear documentation, explainable findings, fast response times, and true partnership. You shouldn’t need a translator or a dedicated liaison just to understand your own recoveries. If you feel like you’re not getting the attention you need, it may be time to look at other options.

3. Your PI partner only catches the low-hanging fruit — and the real leakage keeps slipping through

Sure, basic edits and obvious errors add up. But if your PI vendor is only identifying surface-level issues, the biggest sources of waste are still sitting untouched. Shallow audits produce shallow insights. And that usually looks like:

• Repetitive, low-value findings

• The same coding or billing issues resurfacing every cycle

• Missed patterns in medical records or configuration

• No clarity on what’s causing problems upstream

• A lack of advanced or emerging concept development

When vendors limit themselves to what’s easy to find, you get noise — not progress.

Depth matters. Real program improvement happens when your PI partner can:

• Detect nuanced patterns that require clinical and coding expertise

• Trace issues back to system logic, provider behavior, or benefit design

• Deliver defensible artifacts that withstand appeals

• Help you resolve the source of leakage, not just the symptoms

A high-attention, auditor-led partner doesn’t just add more edits. They reveal what others miss — and help you prevent those dollars from leaking again.

If your PI program stops at low-hanging fruit, you’re leaving major recoveries and long-term improvements on the table.

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The bottom line: You don’t need more tools — you need more attention

Too many PI vendors rely on scale, automation, or black-box technology that prioritizes volume over accuracy — leaving plans with more abrasion, more confusion, and more leakage.

A good PI partner should be:

• Human-led and deeply attentive

• Tech-enabled, not tech-replaced

• Transparent in process and defensible in findings

• Clinically rigorous and auditor-driven

• Proactive in helping you prevent issues, not just reporting them

If your current program isn’t giving you that, upgrading your partner may be the single most impactful change you can make.

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Ready for a PI partner who brings clarity, accuracy, and real partnership?

Penstock delivers deep post-pay expertise, auditor-led reviews, fast response times, and explainable findings that help health plans recover more with less abrasion and more confidence.

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