At the AI for PI Summit 2025, Lynn Garbee, Partner at HealthScape Advisors, delivered a strikingly candid and strategic session that struck a chord with payment integrity (PI) professionals and healthcare industry leaders. Drawing from decades of experience, she made the case for a shift from today’s fragmented, reactive payment integrity processes to an AI-powered, collaborative, and preemptive approach that prioritizes patient care and optimizes real savings through better partnership.

Why Healthcare Payment Integrity Needs a Reset

Garbee opened by sharing her journey—leaving payment integrity over a decade ago because it felt like a futile “whac-a-mole” game. Each cost savings initiative was ultimately canceled out by provider responses. The breaking point came when she realized those efforts didn’t help her own family during a healthcare crisis.

Ironically, she now believes payment integrity strategies are ripe for transformation through advanced technologies—because of artificial intelligence. Her central argument: current payment integrity processes are fragmented, largely focus on postpay claim reviews focused on improper payment recovery, and frequently contribute to rising healthcare costs and compromised provider relationships.  But by streamlining workflows with artificial intelligence and through strategic interventions, the model can shift from reactive healthcare cost control to proactive, value-based care.

From Fragmented to Future-Ready: A Blueprint for PI Transformation

Garbee offered a three-part framework for modernizing PI for operational efficiency:

1. Move Left: Shift to Prepay—and Sooner

Payment integrity should move upstream, ideally into the provider’s practice management system, where claims can be corrected before submission. She cited $17 billion in annual waste from reprocessing cycles alone.

2. Move In: Regain Control Over What Matters

This doesn’t mean in-housing everything, but being selective. Contingency-based vendors often create perverse incentives. By using AI to automate clinical record reviews and prepay audits (like ED coding), payers can reduce abrasion and improve precision.

3. Be Transparent: Communicate Rules and Collaborate with Providers

“There shouldn’t be a black box. There should be an answer key.” Garbee called for formalized, CMS-style communication around edits and policy changes—giving providers clarity and time to prepare.

The Problem with “Fake Savings”

Garbee broke down the flawed economics of contingency-based cost savings. When a health plan recovers funds from overpayments, it often:

• Pays 15% of the recovery to a vendor
• Encourages repeated resubmissions, multiplying claims processing cycles
• Triggers negotiation blowback, with providers seeking reimbursement of the denied amounts through future rate hikes

“The water comes back to the same level,” she quipped, emphasizing that many of these savings are illusory and merely shift cost burdens instead of removing them.

Garbee explained: what looks like a win on a quarterly report often disguises administrative burden, inflated rates, and strained provider relationships. The smarter path is structural change—removing the waste before it starts.

The ER Coding Use Case: A Practical Transformation

Garbee shared a compelling example: ED coding. Level 4 and 5 codes rose from 5% in 2004 to over 55% in 2021. The solution wasn’t blanket denials. Instead, she outlined a more collaborative, AI-driven payment integrity solution:

• Define and publish a policy
• Give providers advance notice
• Automate prepay audits without medical records
• Monitor submission behavior

The result? Less abrasion, faster claim review, and greater alignment between policy and outcomes.

Governance Matters: From Chaos to Cohesion

Garbee highlighted the organizational confusion around PI ownership. At one conference, attendees named eight different groups that “owned” PI within their organization.

Her recommendation: align around an enterprise “North Star” supported by executive stakeholder governance, shared validation metrics, and streamlined vendor strategies.

She outlined five key principles:

• Integrity: Transparent, ethical execution
• Affordability: Reduce admin and vendor costs
• Provider Experience: Minimize abrasion
• Efficiency: High accuracy, low manual effort
• Timeliness: Act within claim windows using automation

Collaboration Over Combat: Reimagining Payer-Provider Dynamics

One of Garbee’s most compelling points: payers and providers are rarely at the same table unless they’re negotiating contracts. Yet they’re deeply entangled in daily operations.

By aligning on edits and policies, providers can send cleaner claims, and payers can reduce denials and delays. These conversations don’t just reduce friction—they enable partnership, trust, and co-designed, AI-driven solutions.

Rethinking the Role of AI in PI

Garbee positioned AI as an enabler—not a cure-all—for smarter payment integrity programs across the healthcare system and better payment accuracy. Specifically, AI can:

• Flag claim errors before submission
• Match documents to policies
• Automate audits
• Reduce resubmissions
• Provide real-time feedback

By focusing on automation and intelligence over blunt-force denials, payers can simultaneously contain costs and foster better provider relationships.

The Road to Zero: Can Payment Integrity Eliminate Itself?

Lynn Garbee didn’t close her talk with safe conclusions—she issued a challenge. What if the most radical, value-driven future for payment integrity is to make it obsolete?

For decades, PI has been the go-to lever when payers need quick wins. Deny, recover, repeat. But as Garbee argues, this cycle is broken. Vendors profit from denials. Providers push those financial losses into future contract negotiations. Administrative costs rise. Patients are no closer to better care.

Her vision?

• Use AI to eliminate waste at the source, not recover it after the fact.
• Shift from detection to prediction, ensuring clean claims are submitted before they ever hit a payer system.
• Replace fragmented teams with centralized governance and shared KPIs.
• Rebuild trust with providers through rule transparency, predictable timelines, and collaborative policymaking.

This isn’t hypothetical—she’s already helping payers implement it. The outcome: less abrasion, more alignment, and a return to patient-centered operations.

In Lynn Garbee’s words: “Those aggressive savings targets should be gone. We should be striving to get to zero.”

Not fewer denials. Not faster clawbacks. Zero. It’s a bold vision for the U.S. healthcare industry. And it’s long overdue.

Join the Movement 

To stay informed and engage with peers leading the future of payment integrity:

• Join the AI for PI Community Group on LinkedIn
• Follow the AI for PI LinkedIn Page for updates and insights

Ready to transform your own payment integrity program? Visit https://pointzeropaymentintegrity.codoxo.com to learn more.