The following is a guest article by Mark Noel, SVP and GM of ClaimInsight at AMPS
As health plans face escalating medical costs and increasing scrutiny over member and provider satisfaction, a critical strategic challenge looms: provider abrasion. This administrative friction driven by opaque payment policies, excessive administrative burden, and retrospective claim denials is more than a nuisance; it’s a direct threat to a plan’s financial integrity and the stability of its provider networks.
For payer organizations, the cost of this friction is a significant drain on resources. Industry data estimates that avoidable payer-provider friction contributes to a billion-dollar problem across the healthcare system. This waste manifests not just in financial leakage, but in internal administrative costs, time spent on disputes, and the erosion of trust, making network negotiation and management exponentially harder. The traditional, reactive model of post-payment recovery is no longer tenable for health plans committed to strong financial stewardship.
The future requires a foundational shift toward Payment Precision a strategy that embeds accuracy, clinical defensibility, and transparency into every payment decision.
Provider Abrasion: The Hidden Cost to Your Plan’s Bottom Line
Provider abrasion is a core issue for payer leadership because it directly impacts business objectives:
- Financial Leakage: Post-payment recoveries are often incomplete, straining internal teams and generating unrecoverable losses.
- Administrative Waste for the Payer: The cycle of claim appeals, provider calls, and internal rework resulting from initial “black box” denials drives up your own operational expenses.
- Network Instability: Dissatisfied providers are more likely to terminate contracts, creating network gaps and impacting your plan’s competitive position and member access. The administrative toll is immense, with practices dedicating significant staff time to tasks like prior authorization and appeals, time that is often directed at the most burdensome payers.
To fulfill your fiduciary duty and maintain high-performing networks, this friction must be proactively eliminated.
Shifting Left: The Future of Payment Integrity is Pre-Payment Precision
The most effective strategy to mitigate provider abrasion is to “shift left”, moving payment integrity interventions to the pre-payment phase. Payment Precision is the result of this strategic shift, defined by three pillars:
- Proactive Prevention: Leveraging advanced technology to identify and prevent improper payments before they exit the system. This maximizes savings retention and drastically reduces the need for contentious, costly post-payment clawbacks.
- Transparency and Defensibility: Providing clear, evidence-based rationale for every payment adjustment. The decisions must be fully auditable and easily understood by the provider.
- Clinical Rigor: For complex claims, accuracy demands more than automation. It requires incorporating objective, physician-led review to ensure clinical and coding changes are indisputable.
ClaimInsight: Your Strategic Platform for Savings and Network Strength
AMPS’ ClaimInsight solution is purpose-built to execute this strategy, empowering health plans to secure financial integrity while reducing provider friction. We solve your dual problem: maximizing savings and strengthening provider relationships.
ClaimInsight achieves Payment Precision through key integrated solutions:
- Intelligent Policy Update (IPU): Our real-time, rules-based editing engine provides your plan with automated, pre-payment claims editing. IPU integrates a continuously updated, comprehensive library of policies, ensuring that edits are applied accurately and defensibly before the claim is paid. This eliminates the “black box” and provides transparent, clear logic for every automated adjustment, drastically reducing the volume of unnecessary denials and subsequent appeals that burden your staff.
- High-Dollar Review (HDR): For the most complex, high-value inpatient claims, HDR delivers physician-led medical bill review. Every claim is examined by a practicing, licensed physician, ensuring unparalleled clinical and coding accuracy. This critical layer of human expertise provides defensible payment decisions that stand up to appeal, with over 95% of our findings upheld. By replacing algorithm-only denials with a physician-backed rationale, you transform a potentially adversarial recovery process into a collaborative interaction.
Enabling Transparency and Operational Excellence
ClaimInsight’s commitment to Payment Precision extends beyond the pre-payment edit engine and clinical review. We also provide the tools and support essential for a streamlined provider experience:
Immediate, Consistent Answers: With Client Claim Search (CCS), your customer service representatives have a fast, single source of truth for every claim. This tool ensures fast, accurate, and consistent messaging back to providers for any questions or inquiries, eliminating internal confusion and accelerating resolution.
Proactive Education: AMPS assistance with provider communication/education helps plans proactively inform their networks about new policies and policy changes, ensuring providers understand payment logic before claims are submitted. This preventative education is a key component of the ‘shift left’ strategy.
The result of this integrated approach is an unprecedented level of payment accuracy and provider trust. ClaimInsight consistently achieves an incredibly low adjustment/appeal rate, typically less than 1%. This metric is unprecedented in the space and serves as the ultimate proof of our precision-first philosophy.
By integrating the speed of automated precision with the credibility of physician review, ClaimInsight enables health plans to realize significant, sustained savings, up to $9 million annually per 500,000 covered lives just from high-dollar claim review, all while demonstrating a commitment to fair and accurate payment. The future of payment integrity is a core strategy for payer leadership.
By investing in technology like ClaimInsight, health plans can eliminate friction, secure their financial position, and build the foundation for collaborative, high-performing provider networks.
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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