The following is a guest article by Jonathan Jeffress, Chief Operating Officer at AMPS
Rising medical costs, greater demand for transparency, and growing pressure from employers are pushing payers to rethink how they manage claims accuracy. Even with strong processes in place, many organizations are discovering that hidden inefficiencies, especially in high-dollar claims, can quietly erode savings. It’s not about missteps, but about the opportunity to do more with smarter tools that bring both speed and clinical depth to every decision.
The Billion-Dollar Oversight
Despite decades of automation and prepay edits, improper payments remain healthcare’s stubborn open secret. A 2024 report from the Office of Inspector General exposed a glaring reality: billions continue to hemorrhage annually from coding errors, undocumented services, and medically unnecessary claims, especially in high-dollar inpatient cases. For Payers, these aren’t just operational inefficiencies; they’re direct threats to profitability and credibility. Every undetected overpayment erodes employer trust, tightens already razor-thin margins, and fuels skepticism about payers’ ability to steward plan funds responsibly.
Why Policy Edits Aren’t Enough
The root issue? Outdated defenses. Many plans rely on policy-driven edits as their safeguard, assuming these rules can catch modern billing complexities. This is a dangerous miscalculation as policy edits alone can miss subtle, clinically nuanced discrepancies that demand human judgment. The result? Payers routinely reimburse for upcoded services, unbundled procedures, or treatments that lack medical necessity often without realizing it until post-pay reviews reveal the damage. By then, recovery opportunities have evaporated, and losses are locked in.
The New Frontier of Payment Integrity
Leading payers are rewriting the playbook. They recognize that payment integrity isn’t a back-office compliance task, it’s a strategic lever to control costs without sacrificing provider relationships or quality of care. This requires a dual approach:
- Precision at Scale: Combine deep clinical logic with proprietary algorithms to detect and correct high-risk claims before payment.
- Clinical Expertise at Scale: Physician-led reviews that apply real-world medical judgment to ambiguous or complex cases.
The goal isn’t just to detect errors, it’s to prevent them proactively. This shift demands tools that are both precise and agile, capable of mining vast datasets without disrupting operations or alienating providers with excessive disputes.
Trust as a Competitive Advantage
Transparency is the non-negotiable currency of modern healthcare. Employers now demand proof of fiscal responsibility, while providers resist adversarial reviews. Payers who balance rigorous oversight with collaboration will differentiate themselves. The winners won’t just reduce waste; they’ll strengthen partnerships by demonstrating how payment integrity protects all stakeholders, from plan sponsors to patients.
The Cost of Complacency
Inaction has a price: A 2023 McKinsey analysis estimated that up to 10% of annual claims spend is lost to overpayments. For a mid-sized plan, that could mean millions left on the table, funds that could bolster benefits, lower premiums, or invest in innovation.
A Smarter Solution: ClaimInsight by AMPS
This is the challenge ClaimInsight was built to solve. ClaimInsight isn’t just another claims editing tool, it’s a next-generation payment integrity platform engineered to solve the most persistent pain points facing payers and TPAs.
By combining a robust policy-driven rules engine, a best-in-class clinical content library, and physician-led expertise, ClaimInsight delivers defensible accuracy and immediate savings before dollars ever leave the door. Built for seamless integration and configurable workflows, ClaimInsight modernizes claim editing while ensuring every high-dollar claim is reviewed with line-by-line precision.
With tools like Intelligent Policy Update (IPU) and High-Dollar Review (HDR), payers benefit from up-to-date policies and targeted reviews of financially risky claims, saving as much as $5M per 100,000 members annually. The result? True cost containment, complete confidence, and faster results at a fraction of the cost of traditional solutions.
The Path Forward
The healthcare economy is shifting irrevocably toward outcomes and accountability. Payers and TPAs can’t afford to rely on yesterday’s tools for tomorrow’s challenges. The time is now to:
- Review the Process: Identify and address your blind spots.
- Embrace Clinical Intelligence: Rules alone aren’t enough. Integrate deep medical expertise into prepay workflows.
- Proactive Measures: Greater savings are achieved by preventing leaks rather than addressing them after they occur.
Payment integrity isn’t just about cost containment, it’s about sustainability. When payers sharpen their oversight, the entire system wins: employers see value, providers maintain trust, and members receive the care they deserve. The question isn’t whether you can afford to act. It’s whether you can afford not to.
About Jonathan Jeffress
Jonathan Jeffress is Chief Operating Officer of AMPS, providing oversight to each business unit ensuring valued delivery of AMPS solutions to the organization’s growing client list. He also leads AMPS Information Technology, Security, Product Development and global operations. Mr. Jeffress has more than 25 years of experience serving healthcare and health insurance organizations, and brings in-depth expertise in business strategy, organizational management, process improvement, implementation/integration, IT, and service delivery. Before joining AMPS, he served as Vice President of Operations, Client Delivery, and Implementation Services at Cotiviti leading the Prospective business unit. His experience also includes management positions at industry leaders Xerox and Lockheed Martin. Mr. Jeffress is an alumnus of the University of Alabama with a business degree in economics and finance.
About Advanced Medical Pricing Solutions
Founded in 2005, Advanced Medical Pricing Solutions (AMPS) is a diversified healthcare technology company supporting transparent, affordable medical and prescription benefits through proprietary software as a service (SaaS) products and tech-enabled services offered across the healthcare payer and employer markets. The company offers a range of products including prospective payment integrity software, high-dollar medical bill review, claim repricing software, reference-based pricing software and services, and transparent pharmacy benefits management, through its business units: ClaimInsight ®, PriceDynamix™, and Drexi™. AMPS ® serves self-insured employers, health plans, TPAs, and individual market aggregators throughout the United States. For more information, visit www.amps.com and www.ClaimInsight.com
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