What is on the horizon for healthcare payer technology in 2025? In this annual report, ClarisHealth experts review the trending drivers – and associated opportunities – so health plans can innovate payment integrity while minimizing risk.
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Maximizing Opportunity with 2025 Healthcare Payer Technology Trends
Buying payment integrity technology: 6 considerations
More health plans see the value in reducing administrative complexity to improve costs and payment accuracy. This step-by-step guide for payment integrity leaders buying enterprise technology ensures you reach those goals.
Payment Integrity Leaders Reveal What Will Move the Industry Forward
Payment integrity leaders from the country’s top health plans take time to collaborate at POP Conference 2024. They find strength in community, innovative ideas, and a focus on 4 primary industry drivers.
Improving Payment Integrity with a Building Blocks Methodology
Payers need a proven framework for payment integrity to create financial value, handle change, and engage at the highest levels of organizational strategy. This 5-step methodology works whether the directive is accelerating growth, building from scratch, or somewhere in between.
Will Artificial Intelligence Finally Make Good on its Promise to Healthcare?
Artificial Intelligence is making the leap from much-hyped “trend” for healthcare technology to more widespread adoption. Here’s what A.I. is — and isn’t — and how health plans are proving its value. Artificial Intelligence for healthcare has come a long way since...
Payers Reduce Administrative Costs by Going Back to Basics with Payment Integrity
In the face of economic and hiring constraints, payment integrity leaders are prioritizing these 4 best practices to shift to an enterprise strategy that offers proven value.
Health Plan Leaders Speak Out on Building the Payment Integrity Organization of Tomorrow
Whether or not health plan leaders implement a fully centralized PIO, sharing information on an enterprise payment integrity technology platform helps overcome challenges and meet strategic opportunity.
Study Reveals Payers Recover Overpayments 50% Faster with Enterprise Technology
In an industry that has struggled to quickly and meaningfully address healthcare claims payment accuracy, digital transformation once again proves its value. How can payers best take advantage of the potential of enterprise technology?
Payment Integrity Leaders Ready For A New Normal
With the ever-changing outlook of the payment integrity industry, now is the time to get ahead by making strategic investments in change.
ClarisHealth Named a Preferred Vendor by the Association for Community Affiliated Plans
ClarisHealth named a preferred vendor by the Association for Community Affiliated Plans, provides unique payment integrity and FWA technology platform for ACAP member Safety Net Health Plan digital transformation goals.
A Better Way to Conduct Medical Claims Audits
With advanced technology, health plans can take control of their medical claims audits while achieving high ROI. Here’s how.
Vendor Consolidation Reduces Payment Integrity Innovation
What steps should your health plan take to ensure you get the most value from your services vendors and payment integrity efforts in the face of vendor consolidation?
Are You Hurting Provider NPS with Your Payment Integrity Efforts?
Look out for these 4 elements of payment integrity that may negatively impact provider NPS (net promoter scores) with your network providers. The Net Promoter Score (NPS) – an established metric traditionally managed by insights and marketing departments – can drive...
The Strategic Approach to Claims Cost Containment
Competing with other health plan functions for technology priority can lead to missed audit claims cost savings potential. An integrated payment integrity strategy breaks down these internal silos. With so many moving – and vital – parts within a payer organization,...
Using A.I. to Unite Fraud and Payment Integrity
Part 1 of our series on how the SIU can use artificial intelligence to overcome common challenges. Bringing together fraud and payment integrity efforts on a single A.I.-powered platform can accelerate health plan savings. Data and work silos have become a top barrier...
How to Evaluate Payment Integrity Solutions: The Ultimate Guide for Health Plans
Payment integrity solutions vendors make many claims. Here are the top 14 areas of evaluation to ensure a perfect fit for your health plan. Virtually every health plan is looking to address shrinking margins by moving their medical savings from a typical 1-2% today to...
Evaluate Payer-Provider Portals on These 4 Features
Go beyond the basics with a payer-provider portal that drives engagement and decreases costs. How would you characterize the health of your relationships with network providers? If yours is like many health plans, those relationships could always improve. And...
5 Steps to Reducing Fraud, Waste and Abuse
Use these tech-enabled tips to comprehensively reduce FWA. States require MCOs to take proactive measures that reduce not just fraud, but also waste and abuse. But how can you ensure your efforts not only meet compliance requirements but also help secure a competitive...
Your 5 Point Clinical Audit Checklist to Reduce Provider Abrasion
In part 2 of our series we outline exactly what health plans should look for in an advanced technology platform for clinical audit Paying claims right the first time – while making the most of internal resources – is the primary goal at most payer...
“The Great Pause” Brings Unyielding Uncertainty to Medical Loss Ratios but Also Opportunity
Are better-than-expected medical loss ratios in 2020 setting up payers to take a severe hit on profit margins in 2021? Go on offense by making moves that feature these 4 risk-mitigating hallmarks. Six months into the novel coronavirus pandemic in the U.S., the crisis...
The Strategy Nearly Every Health Plan Considers: Outsource vs. Insource
Slim margins, fewer resources, and consolidation have made it harder for health plans to compete. Could balancing outsource vs insource efforts accelerate their goals? With shrinking margins, fewer and fewer internal experts, and increasing consolidation, health plans...
What’s your best path to adopting advanced FWA technology?
Take this interactive self-assessment to evaluate your current SIU successes and determine your health plan’s need for advanced technology to level up your fraud, waste and abuse mitigation efforts. More advanced technology solutions for healthcare fraud detection,...
You Don’t Need Rules to Mitigate Healthcare FWA
Health plan SIUs find deep learning models for fraud detection provide advantages over rules-based tools. The onset of the novel coronavirus pandemic highlighted a glaring weakness in rules-based FWA systems: the need to develop rules well ahead of their actual use...
3 Ways MCOs Can Prevent Fraud, Waste and Abuse
A robust fraud, waste and abuse program at MCOs and MAOs includes three key areas: Technology, Clinical Audit and Investigative capability. As your health plan grows its fraud, waste and abuse initiatives, there are three areas a strong prevention plan should address....
6 Steps to a Successful Prepay Strategy
Health plans can take control of their own prospective provider audits instead of over-relying on services vendors with the help of advanced technology and access to proven analytics. We’ve written before about why it’s important for health plans to start thinking...
5 Reasons for Health Plans to Choose a Scalable Payment Integrity Technology Platform
Are you using an assortment of software tools to do work better suited to a platform? You might be missing out. When your health plan starts looking to upgrade your payment integrity and fraud management processes with technology, what do you turn to? A tool or a...
Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis
Transparent data sharing supports seamless care coordination, relevant outreach that mitigates effects of chronic conditions. The novel coronavirus pandemic continues its near-perfect record as a harsh but effective teacher for the healthcare industry as it...
Health Plans Return to Payment Integrity
3 claims trends associated with the healthcare industry getting back to business, and how health plans can smoothly resume payment integrity efforts. Now that the crisis-volume of COVID-19 cases has started to ease across the country, delayed elective procedures and...
Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis
Coronavirus highlights power of big data and the need for interoperability to improve population health. How can health plans lead the way? What’s the single biggest weapon used by government, pharma, academic researchers, healthcare systems, and health insurers alike...
From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis
As patient volumes drop due to the COVID-19 pandemic, fee-for-service payment models hurt providers. Is this finally the time for value-based care? COVID-19 is decimating provider finances. Hospitals are losing over $40 billion per month in lost revenue due to...
Coronavirus New Normal: What does it mean for health plan members?
25 million Americans projected to lose employer-sponsored healthcare coverage due to the COVID-19 recession. How will this disruption affect the relationship between health plans and consumers? As of the end of April 2020, about 30 million people in the U.S. are newly...
Coronavirus Boosts Telehealth Adoption
The COVID-19 pandemic prompts payers to encourage the shift to telehealth, a move supported by patients and providers. How will this change the future of healthcare delivery? The novel coronavirus stopped traditional healthcare in its tracks, but there’s one bright...
Coronavirus Crushes Providers. Health Plans to the Rescue!
To support healthcare providers financially impacted by COVID-19, health plans rush to provide funds, ease administrative burden with prepay and engagement initiatives. Right now, the healthcare industry is in the thick of the novel coronavirus pandemic, with...
Your health plan’s best crisis response strategy? Innovation.
Health plans set themselves up for success – during a pandemic and beyond – by pursuing advanced technology to engage providers, satisfy members, and improve population health initiatives. The healthcare system is on the front lines of the novel Coronavirus pandemic,...
Do You Have a Healthcare Fraud Prevention Strategy Ready for COVID-19?
Artificial Intelligence allows health plans to more nimbly address FWA while reducing false positives To make an obvious understatement, the new coronavirus (COVID-19) pandemic is an event like we’ve never seen. While essentially the whole country is shut down, the...
Try Before You Buy: A bottom-up approach to health plan technology adoption
Why flipping the script enterprise software is the future of digital transformation? Have you ever tried a piece of technology at your health plan before it was adopted by the broader organization? Think about solutions like MailChimp, Survey Monkey, Slack and...
Health Plans: Take These 4 Steps to Comply with New Information Blocking Rules
Now that the rules promoting interoperability have been finalized, here’s how payers can prepare to take full advantage of the freer exchange of healthcare data. On March 9, 2020, the two separate rules issued by CMS and ONC against Information Blocking became final....
Diving Deeper into Healthcare Claims Audits: Part 1 – Auditor Workflow
The first installment in a multi-part series aimed at clinical auditors. Part 1 takes a closer look at 5 trends impacting how health plans manage claims auditing today. Claims auditing. It’s the core function of any health plan payment integrity operation. Ensuring...
Should Your Health Plan Build or Buy a Technology Solution?
Flexible solutions offer greater value to health plans. Whether your health plan has decided it has outgrown its manual paper-based processes or existing technology, at some point you will likely ask, “Should we build our own custom solution or buy something off the...
Data Privacy Concerns Meet Digital Progress
Data privacy and security will always be top of mind for health plans in an environment where access to data is crucial to growth. Here are some safeguards for payers. How do payers balance their need for broader access to data with their need to improve trust with...
Top 10 Reasons Health Plans Choose Pareo
It’s almost 2020, and forward-thinking health plans have a choice when it comes to total payment integrity solutions. From smaller regional plans with 100k members to large national health plans with millions of lives covered, Pareo scales to accommodate all needs....
Your FWA solution may not be as modern as you think.
The package may have changed, but the truth is most FWA solutions are still relying on legacy technology. 3 ways to spot the difference. To prepare for the advancing disruptions to healthcare, most plans we speak with have made some progress towards digital...
Where does your health plan reside on the payment integrity continuum?
Take this interactive self-assessment to determine how much progress your health plan has made towards modern digital transformation. The goal for every future-looking health plan is to transition payment integrity efforts from predominantly external post-pay, to a...
Tracking the Information Blocking Rule: It’s nearly final, but is the healthcare industry ready?
Despite public concern, the final rule is moving forward. Meanwhile, a recent survey says only 18% of healthcare execs understand the seismic implications. Both the Information Blocking Rule and the Interoperability Rule (collectively referred to as the Proposed...
No, Healthcare Can’t Pursue Fraud like Credit Card Companies. Here’s Why.
For consumers, the credit card fraud prevention experience is seamless, which leaves many health payers wondering why they can’t access the same technology. The short answer? It’s complicated. It’s easy to see how health payers, who have become disenchanted with...
Behind the Curtain: What to expect when you implement Pareo
Pareo is a unique platform that integrates with other software solutions to provide a comprehensive look at a health plan’s payment integrity processes. Here’s how we approach implementation of enterprise technology. Just got word that your health plan is adopting...
Why we focus on the problem, not the health care solution
ClarisHealth CEO Jeff McNeese shares how our tech company created a solution born directly out of the frustrations with the healthcare industry, by experienced healthcare workers. A major health plan client came to us recently and asked “Can you partner with us on...
Time to get social! How to cover social determinants of health without increasing complexity
Payers are starting to go all-in on social determinants of health, but coordination of care can be complex. A look at how technology can manage these high-impact initiatives. Already a trend for Medicaid, and now gaining steam among Medicare Advantage plans, payers...
Here’s What You Don’t Know about Fraud, Waste and Abuse
Fraud is different from Waste and Abuse, and most technology solutions don’t adequately address either issue. Think you know how to manage fraud, waste and abuse at your healthcare organization? CMS doesn’t agree. In fact, the promises of change and reform coming from...
Using API integration to Create a “Central Hub” of Data
As API integration becomes the norm, health plans are learning not all health information technology is created equal. With the release of the 2015 Edition Final Rule, API integration for electronic health records became required. Its direct effect on patients and...
An Aggressive Plan to Move your Claims Recovery to Prepay Status
Transitioning more payment integrity operations to internal prepay is more than just a pipe dream for health plans Transitioning prepay. It’s the holy grail for health plans — and viewed as equally unattainable. And, in the not-so-distant past, this viewpoint would...
Data Interoperability Solutions Start with the Consumer
Why a consumer-first mentality may be the best way to comply with Information Blocking rules. If we were to ask you what your health plan’s digital strategy is, would you have a ready answer? Don’t worry: this isn’t a pop quiz and we aren’t grading you. We can’t say...
Managing Medical Record Requests a problem? We’ve got the solution.
How to manage medical record retrieval processes with multiple clinical audit vendors.Is your health plan missing out on the potential of having multiple clinical audit vendors because you’re concerned about overlapping medical record requests? That uncoordinated...
5 Keys to Help Your Health Plan Focus on 2020
No crystal ball needed. Here’s what we see successful health plans doing now to prepare for 2020. It seems like once Labor Day passes, we prepare for the last half of the year no matter what the weather does. Pumpkin everything, dreams of cooler weather and … 2020...
Modernizing communication with providers
Time to move past playing telephone with providers. Here’s a better communication strategy for health plans. By relying on fax machines and snail mail to communicate overpayments, underpayments, denials, and just about everything else, the payer-provider relationship...
Be the change agent you wish to see at your health plan
8 essential skills every change agent needs to navigate the future of healthcare Whether you’re already leading change at your organization or hoping to do so soon, most health plan employees need to be well versed in change management as the industry braces for rapid...
Prepare to Meet the Future with Data
We revisit ONC’s Information Blocking Rule, recap public comments, and look at how health plans can meet data sharing requirements. Earlier this year, we wrote about the ONC’s proposed information blocking rule and how it serves as an opportunity for health plans....
Can your tech do this? How to enhance your health plan members’ digital experience.
Health plans are shifting focus to ensure member satisfaction. Here’s how technology — even internal solutions — affect the digital experience of your health plan’s members. Do you ever think about how different banking is now compared to 10, 20, 30 years ago? First...
What makes value-based care programs work? 3 keys to success
Following up on our previous article, we look more closely at what successful value-based care initiatives have in common. It’s not all that surprising that one of our recent blog posts, Medicare for All: Should it be feared by health plans? has quickly become one of...
Should You Build Your Own Supplier Management Solution?
Take our quiz to help you decide if build or buy is right for your health plan. By now, you likely realize that your health plan needs a way to manage the many third-party vendors that allow you to maximize recoveries and optimize costs. The question is, should you...
Creating a Community of Users
When you adopt Pareo®, you gain access to a large community of health plan professionals offering shared expertise. From time to time, we like to remind our readers that “you don’t have to go it alone.” That isn’t just an empty catchphrase we use to market to new...
Forget the Buzzwords. Lack of progress now doesn’t mean you’ll never catch up.
3 practical steps you can take today if your health plan is feeling left behind on advanced payment integrity technology A few weeks ago, a blog reader approached me about a recent article I wrote titled “Does Your Health Plan Even A.I.?” The reader, who also happens...
Burned out and Bored? Remind Your Employees Why Payment Integrity Matters
Address the “why” behind payment integrity and you’ll find that health plan employees no longer feel stuck. Most talented employees start out in their jobs with a great deal of optimism: meeting new people, learning new things, looking forward to making a positive...
Can your self-built technology solution do this? Why iterative software development is essential.
Health plans considering self-developed payment integrity technology should ask themselves: Do we have the resources to be agile? Iterative Software Development: A cyclical method of software development which focuses on improvements based on continual revisions and...
Health plan of the future? It starts with data sharing.
Here’s what ONC’s new “information blocking” rule means for your health plan. In February, the Office of the National Coordinator for Health Information Technology (the ONC) announced a new proposed rule to prevent “information blocking.” Interoperability has long...
6 Signs of Outdated Payment Integrity Processes
Working harder and harder for a 1-2% rate of return on claim spend? It’s time to update your health plan’s payment integrity processes. Today, health plans and payers are at a crossroads: margins are shrinking, members are savvier, providers are increasingly...
Status Emails Drain Health Plan Productivity
If your auditors’ workflow depends on email, there’s a more productive way forward. Confession time, health plans: how much of your auditors’ workflow depends upon email? Are they working claims based upon what they were pinged about most recently? You’re not alone....
Top 10 Ways to Maximize Your Health Plan’s Recoveries
Want to maximize your health plan’s recoveries? Of course you do. Here’s how.There’s a great deal of uncertainty in healthcare today, but one thing never changes: health plans’ desire to grow their recoveries. But, stuck dealing with insufficient technology or...
Provider to Health Plan: It’s not me, it’s you.
Are you playing a costly game of “Who’s got the medical record”? 90% of your health plan’s cost containment efforts are the source of provider friction. Your health plan has one directive: control medical spend. And despite tight timelines, a shortage of skilled...
Put on your cape. Your health plan may just save the healthcare system.
Health plans are in a unique position to innovate with a trickle-down effect on providers and healthcare as a whole. It’s the plot to your favorite superhero movie (and with good reason): The odds seem insurmountable, and the path unclear but there’s a hero who sees a...
A Custom FWA Solution for Smaller Health Plans
Out-of-the-box Fraud, Waste and Abuse solutions just don’t cut it for smaller health plans. If you lead a health plan with fewer than 250k covered lives, you may think you’re out of luck when it comes to a comprehensive FWA solution. Some of the larger technology...
Top Trends for Healthcare Payer Technology in 2019
A look at the drivers, restraints, challenges and opportunities for healthcare payer technology in 2019. To view our 2020 industry forecast, click here. It’s 2019: do you know what’s going to happen in healthcare payer technology this year? We’re taking a thoughtful...
Best Practices for Successful Technology Adoption
A look at some of the barriers to successful technology adoption. There must be a method to the madness. New technology solutions appear to be a dime a dozen, and it makes sense to take a modular approach to implementation. At least, that’s what our clients are doing....
Claim Spend – Is It Too High at Your Health Plan?
Examining claim spend cost at health plans, and what kind of ROI can be expected. Controlling claim spend is nearly impossible without system visibility. By that, we simply refer to the access that some technology gives health plans and payers into payment integrity...
Here’s Where Provider-Payer Relationships Need to Improve
Communication breakdowns with providers wreak havoc on a payer’s bottom line. Imagine, if you will, two scenarios in a relationship between a healthcare provider and a health plan. In one, a provider receives a letter from a health plan telling them a claim is...
Thoughts on Creating a Centralized Payment Integrity Department
Does it make sense for your health plan to carve out Payment Integrity from your other cost containment efforts into a dedicated department with greater oversight capabilities? Historically, payment integrity efforts have been scattered among specialty departments...
Prepare for CMS Audits: A Guide
Here's what to expect following new CMS payment integrity initiatives, including a guide to CMS audit protocols. The pressure is on for state-administered Medicaid programs (and the MCOs that run them). New initiatives released over the summer by CMS promise increased...
How to Maximize Vendor Partnerships with Pareo®
Payment integrity vendors are critical to the success of any health plan. As health plans realize this, they are working to create stronger partnerships. Here’s how Pareo® helps. We were talking to a health plan recently about our comprehensive payment integrity...
How to Reduce Administrative Costs for Coordination of Benefits
Make Your Processes More Efficient for COB Cost Savings It has been estimated that the administrative costs for coordinating benefits is $800 million. Let that sink in for a second – $800 million is a lot of money to spend on a process that can be improved. Other...
Stop Spinning Your Wheels
How to get your health plan out of a rut and break down big data silos. Health plans are tasked with deriving ever-more savings from their claims overpayment initiatives. But with limited people, strategy, technology or processes to accomplish their goals, are they...
Health Plan Member Satisfaction is the Price of Provider Abrasion
Is provider abrasion undoing all your best member satisfaction initiatives? After a recent medical appointment, I visited the front desk on the way out where the office manager/claims specialist let me know I had an outstanding balance from my preventive care visit...
Escape Your Spreadsheets
An expert guide for health plans seeking to digitize big data and improve productivity in payment integrity and across the enterprise. Spreadsheets are useful and can be a very powerful tool in the right hands. But are they really the best your health plan can do to...
Why Now is the Right Time for Implementation
Total payment integrity implementation can help you right now – even if your health plan is in the middle of a claims system project. You know that old saying, “The best time to plant a tree is 20 years ago. The second-best time is now.”? It’s a similar situation with...
Health Plan Vendors Don’t Have to Be a Hassle … If They’re Well Managed
Gain the oversight you need to manage your health plan’s third-party services providers. Recently, a client shared with us that the IT cost to bring on a health plan vendor was $70k. That stopped us in our tracks. $70k is, in our opinion, way too much for a health...
Payment Integrity in Action with L.A. Care Health Plan
Enjoy our on-demand case study presentation. What does total payment integrity look like once implemented? To answer that question, we invite you to view “Bringing Total Payment Integrity to Light: A Case Study with L.A. Care Health Plan” an on-demand payment...
Don’t Settle for “Just” A Claims Editing Solution
Look beyond claims editing solutions and find a comprehensive solution to payment integrity. If your payment integrity strategy is limited to just a claims editing solution, your health plan is falling short on the payment integrity continuum. Health plans that think...
Smaller is Better
Working with a small provider offers big opportunities for health plans In the world of healthcare, the concept “bigger is always better” often prevails. Superficially, it makes sense that a health plan can mitigate risk by working with a large company that has big...
5 Ways Health Plans Can Leverage Big Data
Health plans, don’t let your data go to waste In healthcare, disruptive innovation lately centers around the Big Data Revolution. And for many established health payers and plans, talk of overhaul can seem overwhelming. Changes trickling in over the last several years...
3 Considerations When Discussing Technology Change
A discussion guide for Health Plans Would you be surprised to learn that there were prominent naysayers of innovative (and now common) technologies, such as the iPhone, television and even automobiles? Each of these innovations proved revolutionary and have become a...
Maximize Value & Partnership with Your Third-Party Payment Integrity Vendors
Ask yourself these 6 questions to get the most from your payment integrity vendors. Looking to get the most out of your third-party payment integrity solution vendors? Consider asking yourself the following questions to determine if your vendors are providing you with...
What’s your ROI on a Payment Integrity Technology Solution?
Good return vs. bad return on investment and how your health plan can tell the difference When shopping for a payment integrity solution, you will understandably have many questions. Your COO is going to wonder how this software will improve operations, your IT...
4 Reasons SaaS is Your Ticket to Total Payment Integrity
Cloud solutions are more secure than you may realize, and offer intrinsic benefits for health plans. Software as a Service (SaaS) has revolutionized the way technology in business is used. But many health plans are hesitant to rely on SaaS, often because of...
Best Payment Integrity Results at The Most Optimized Cost
Integrative Audit and Recovery Solution Offers Top Value for Healthcare Payers Many of the healthcare companies we speak with often express concern when reconciling the concept of comprehensive payment integrity with day-to-day operational stressors, such as lowering...