Reducing wasteful spending and ensuring claims are paid correctly
Putting the right checks and balances in place at each stage of a claim’s lifecycle may help protect employees’ dollars and lower costs for employers.
Each year, health care costs seem to rise at considerable rates, with health care expenses expected to reach $6.8T by 2030.1 Even more concerning: 25% of that cost is considered wasteful or unnecessary due in part to administrative errors, fraud and abuse (whether intentional or unintentional) and failures in appropriately coordinating and managing patient care.2
That’s where payment integrity comes in. Payment integrity is all about ensuring employees and their employers are only paying for care or services rendered — and not a penny more. To help achieve that, UnitedHealthcare is working with providers to implement a series of checks and balances across each stage of a claim’s lifecycle, including:
- Pre-claim: Ensuring billing and coding accuracy before a claim is submitted
- Pre-pay: Correcting billing and coding mistakes once a claim has been submitted
- Post-pay: Resolving payment errors after a claim has been paid
While many carriers are tackling payment integrity, not all payment integrity programs work the same. That’s why employers should consider the solutions that are available to them, their potential savings and how a carrier’s payment integrity program fares against others in the market.
$6.8B
saved in 2023 with UnitedHealthcare Payment Integrity model3
“Reducing waste and ensuring claims are submitted and paid accurately matters, especially since managing the cost of health care is a top priority across the industry,” states Harold White, vice president of payment integrity operations for UnitedHealthcare Employer & Individual.
UnitedHealthcare is constantly evaluating its payment integrity process and recently made enhancements to its solutions, using data and analytics to provide a strategic roadmap leading to a more holistic payment integrity model.
And to optimize visibility and produce better results, initiatives are focused on moving accuracy to the earliest possible point in the claims cycle. In 2023 alone, this approach saved over $6.8B in claims errors, including $4.9B in prepayment savings and $1.9B in recovered payments.3
Helping control costs and improve claims accuracy
UnitedHealthcare Payment Integrity solutions proactively work to help lower the total cost of care for employers by reducing payment errors. Payment integrity ensures health claims are paid by the responsible party, using an end-to-end approach across all 3 phases of the claim cycle. Using this methodology, employers see a $32–$35 savings per member per month (PMPM).3
Phase 1: Pre-claim
In the pre-claim stage, before a provider even submits a claim, they are educated about how to price bills accurately and directed to the UnitedHealthcare provider communication portal to review for accuracy. The goal of the pre-claim phase is to correct any mistakes before a claim is submitted for payment.
Phase 2: Pre-pay
After a claim is submitted but before a payment is issued, billing and coding mistakes are corrected through proactive monitoring to help reduce administrative costs and prevent incorrect claims from entering the system in the first place. This phase helps avoid over or underpayment and the potential need for costly and time-consuming corrections during the recovery stage.
Phase 3: Post-pay
If a payment is made in error, a retrospective effort including data mining and review is conducted to help understand why the error occurred, streamline the resolution process and reduce recovery turnaround time.
UnitedHealthcare Payment Integrity solutions drive savings for employers and employees
A third-party survey of providers and carriers conducted by ZS Associates found that UnitedHealthcare payment integrity solutions were the “most thorough” in the market and drove higher total cost of care savings when compared to other top national insurance carriers.4
