Redefining the Future of Payment Integrity & Healthcare Costs: Five Imperatives for Payers & Providers

Navigating a Pivotal Inflection Point 

The U.S. healthcare system stands at a critical juncture. With the cost of care continuing to rise (up to $400B due to administrative waste) and provider burnout reaching unsustainable levels (43% as of 2024), stakeholders across the ecosystem are recognizing that yesterday’s approaches to healthcare payment integrity (PI) are no longer sufficient. The key themes emerging from the 2025 AI for Payment Integrity Summit serve as a blueprint for what the future of U.S. healthcare demands: smarter, more collaborative, and AI-powered automation models that put both patient outcomes and provider experience at the forefront.

The 2025 AI Summit revealed five key imperatives that will define the future of healthcare cost containment. These insights should be at the core of every payer and provider payment integrity strategy moving forward.

1. Move Payment Integrity Upstream 

The traditional paradigm of addressing inaccuracies after a healthcare claims review is reactive and costly. Leaders in the industry are pushing for a proactive approach that integrates payment integrity earlier in the care and billing journey—shifting postpay to prepay, and prepay to pre-claim. 

Through early payment integrity efforts before claims processing or claims auditing, and proactive provider education at the earliest point in a provider’s workflow, organizations can prevent incorrect submissions before they leave the practice management system, and thus also prevent discrepancies and denials. This will dramatically enhance the accuracy and efficiency of provider billing.

Payment integrity solutions that leverage healthcare generative AI innovations are already enabling smarter decisions at the front lines of healthcare providers’ care—a crucial shift for those serious about sustainable cost containment. Read more about upstream payment integrity programs in this blog on pre-claim early intervention.

Addressing issues before claims are created, such as through pre-claim provider education, can yield over $12–16 PMPY in savings per member and reduce overpayments by as much as 40%.

2. Break Down Silos Between Payment Integrity Teams and Data 

Many healthcare payer organizations operate with fragmented teams—prepayment and postpayment, clinical, SIU and provider relations—that rarely communicate or collaborate. This leads to time-consuming duplication of effort, misaligned outcomes, and operational inefficiencies.

To advance payment integrity, healthcare organizations must rewire their internal structures to foster collaboration and shared accountability. Unified, AI-driven platforms that centralize advanced analytics, case management, and provider education can help ensure that all stakeholders are operating from a common source of truth. The result? Faster insights, greater payment accuracy, and reduced administrative costs.

3. Redesign the Provider Experience 

Payment integrity efforts have often been seen as punitive or adversarial, especially by providers. Current efforts can inadvertently create friction, add administrative burden, hurt reimbursements, and detract from the patient experience. It’s time to change that.

Forward-thinking organizations are working to foster better payer-provider collaboration and transform payment integrity from an obstacle into a collaborative joint effort with providers that lowers healthcare costs. Transparent claims data and AI tools that foster provider education, collaborative communication strategies, and shared goals for patient care are foundational to this change. The best provider education portals address the glaring gaps in today’s provider education and enable transparency and self-auditing to guide decision-making. When providers feel supported instead of surveilled, real-time outcomes improve for both patients and the bottom line.

Proactive education and coding accuracy interventions can streamline claim submissions and have shown to improve provider satisfaction by 62%, while enabling up to 90% automation in workflows—reducing provider abrasion and improving healthcare payers’ operational efficiency. And both payers and providers experience cost savings.

4. Establish Executive Leadership and Governance in PI

“Who owns payment integrity?” This question continues to plague many healthcare organizations. Without clear C-suite sponsorship and governance, payment integrity programs remains disjointed, underfunded, and reactive.

Establishing a centralized, enterprise-level command structure is essential. When PI leadership is embedded within the executive suite, it gains the visibility, resources, and cross-functional alignment needed to drive claims payment accuracy and healthcare cost transformation. From fraud detection to provider engagement and billing accuracy, a unified vision can deliver significant ROI.

5. Replace the Black Box with Transparent, Explainable AI 

Trust is paramount in healthcare. Yet, many existing payment integrity solutions operate as opaque black boxes that offer little visibility for providers into how claim decisions are made. This erodes provider trust and leads to costly, unnecessary appeals.

Explainable AI is the way forward. When systems clearly “communicate the rules” in advance and show the rationale behind payment decisions, it builds provider confidence and reduces coding errors—this is where shifting payment integrity processes further left with pre-claim provider education comes in. 

The Path Forward 

The payment integrity landscape is evolving rapidly. These five imperatives underscore the urgent need for cutting-edge innovation that is not only technologically advanced but also grounded in transparency, collaboration, and shared accountability for both payers and providers.

Healthcare leaders who embrace these changes will not only reduce improper payments but will also improve provider relations, reduce friction, and support better care delivery across the healthcare industry.

Join the Movement 

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

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