A provider receives a denial on a high-cost claim they believed was clean and compliant. No explanation, no context — just a rejection. What follows is predictable: Overloaded call centers, delayed resolutions and a costly back-and-forth that strains relationships.

For many health plans, this kind of friction isn’t the exception — it’s the norm. And it’s not just frustrating. It’s expensive, inefficient and damaging to provider relationships.

But here’s the good news: payment integrity doesn’t have to be a source of abrasion.

In fact, when done right, it can be a powerful driver of operational efficiency and trust.

Take a look at four strategies that can help you modernize your approach and make payment integrity work better for everyone involved.

1. Pair AI with Human Expertise for Smarter, Faster Decisions

AI is great at spotting patterns. It can scan thousands of claims in seconds, flagging anomalies that would take a human hours to find. But when it comes to clinical nuance — like whether a high-cost drug is actually appropriate for a patient — AI alone can’t make the call.

That’s where human expertise comes in.

The best programs use AI to support claims review while also ensuring trained clinicians, coders and pharmacists make the final decision. This combination leads to more efficient reviews, fewer errors and decisions that are more likely to stick. That means fewer appeals, less abrasion and more confidence for payers and providers alike.

2. Streamline and Consolidate for Greater Savings and Scalable Operations

If your payment integrity process feels like a game of vendor Jenga, know that this is a common challenge for many health plans.

Many health plans still rely on a patchwork of vendors — one for pre-pay edits, another for post-pay reviews, a third for audits. It’s complicated, inconsistent and expensive.

Simplifying that setup — by consolidating vendors or choosing a partner that integrates across them — creates real value. A single partner can spot multiple savings across the entire claims lifecycle, reduce duplication and deliver faster, more consistent outcomes for providers.

You reduce administrative burden and unlock savings across operations, provider engagement and strategy:

• Fewer handoffs and cleaner workflows
• Less duplication and record requests
• Insights across the full claims lifecycle

This goes deeper than simply cutting costs. These are also strategic changes that ensure you create a system that scales.

3. Communicate Clearly to Cut Through the Friction

Here’s a truth every health plan knows: providers don’t push back because they want to – they push back because they don’t understand the decision.

When claims are denied without context, it feels arbitrary. When coding rules change without notice, it feels unfair. And when providers are left out of the loop, it erodes trust.

That’s why proactive communication is so powerful.

Whether it’s through newsletters, forums or direct outreach, educating providers on what’s changing and why builds transparency and reduces abrasion. It turns payment integrity from a black box into a shared process. And that shift can make all the difference. 

4. Support In-House Teams by Outsourcing Strategically

Many internal teams are already stretched thin. Between managing member services, benefits and compliance, there’s not a lot of bandwidth left for complex, high-volume claim reviews.

Outsourcing payment integrity doesn’t mean giving up control. It means giving your team the space to focus on what they do best.

A strategic partner brings scale, innovation and specialized expertise that’s hard to replicate in-house. They stay on top of evolving regulations, bring proven processes and help you deliver better outcomes without burning out your team. That’s especially valuable as claims continue to grow more complex and regulations keep evolving.

A Better Path Forward

Payment integrity doesn’t have to be a pain point. With the right strategies — and the right partner — it can be a source of strength.

You can improve accuracy, reduce abrasion and identify multiple saving opportunities at every stage of the claims process. Even better: You can do it in a way that supports your team and strengthens provider relationships.

Learn how to balance efficiency and provider relationships — download the full whitepaper.