By: Steve Palma, President of Penstock
Historically, payment integrity has been a common source of friction between health plans and providers. Retrospective audits, recovery efforts and claim disputes have often felt more like battles than shared problem-solving. But as both sides face increasing financial pressure, the conversation is shifting—from confrontation to collaboration.
The stakes are high. With CMS reporting tens of billions in improper payments annually, payers must pursue accuracy. Yet doing so without alienating provider partners requires a different approach—one grounded in transparency, communication and mutual respect. Leveraging Audit & Recovery Services can help ensure that recovery efforts are handled with precision and transparency.
Post-Pay Payment Integrity Strategies: Moving Beyond the “Gotcha” Mentality
Traditional post-payment strategies often suffer from a “gotcha” dynamic—audits arrive with little warning, providers feel targeted and appeals become the default. But the most effective plans today are taking a more sophisticated tack.
They’re engaging with partners who view integrity not just as a numbers game, but as a relationship discipline. That means clear documentation of findings, consistency in logic, and outreach that’s focused on education rather than escalation. It means treating providers as part of the solution, not just the subject of review.
When done well, even post-payment reviews can build trust—especially when providers understand why something was flagged and how they can avoid future issues. The result? Fewer appeals, faster resolution, and a more cooperative working environment.
The Right Payment Integrity Partner Will Help Ease Provider Friction
Technology plays a key role—but it’s not just about better detection. It’s about better communication.
Some of the most promising advancements in payment integrity aren’t algorithmic at all—they’re operational. Centralized portals that give providers access to real-time audit updates. Embedded support teams that explain findings and help resolve disputes. Dashboards that track patterns over time to reduce repeat issues.
These aren’t just features—they’re signals that a partner understands the human side of the process. And that understanding makes all the difference when the goal is not just recovery, but lasting improvement.
Why Payer-Provider Collaboration is Now a Competitive Advantage for Health Plans
As value-based care gains traction and network relationships become more strategic, payers can no longer afford integrity approaches that generate friction. Provider dissatisfaction is no longer a soft metric—it’s a business risk.
That’s why the most forward-looking organizations are rethinking the integrity function as a relationship engine. One that supports fiscal responsibility and partnership sustainability. One that sees clarity, consistency and collaboration as core metrics—right alongside dollars recovered. Collaborative Payment Integrity Consulting can help align these goals by facilitating collaboration and ensuring that both payers and providers are working toward common objectives.
What to Look for in a Payment Integrity Partner
For health plans focused on building smarter, more provider-aligned integrity programs, a few traits stand out:
- Clear, Evidence-Based Findings: No black boxes—just understandable, defensible logic.
- Dedicated Provider Support: Human conversations that reduce provider confusion and defensiveness.
- Configurability Without Complexity: Tailored logic and workflows that fit your plan’s needs without burdening your teams.
- Commitment to Reducing Friction: A focus not just on recovery, but on relationships.
Every health plan is under pressure to do more with less. And in payment integrity, the true measure of value is no longer just the dollars recovered—it’s how seamlessly those recoveries are achieved.
According to the 2024 industry-wide survey, many health plans are actively reassessing their vendor relationships, not only to improve financial performance, but to reduce provider abrasion. The message is clear: plans are no longer just looking for auditors. They’re looking for true partners who make the process easier for everyone involved.
As post-payment reviews remain a cornerstone of payment integrity programs, the question isn’t whether you need outside support, it’s whether that support acts as an extension of your team or a source of ongoing tension.
Payment integrity is evolving. Not toward more confrontation, but toward more collaboration. The most successful plans are partnering with vendors who understand that sustainable recovery depends not just on what you find, but how you work with others to fix it.
