The Shift Toward Prepay Prevention in Healthcare Payment Integrity
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Guest Author
Summary
This guest article by Steve Sutherland, SVP Information Systems at CERIS, discusses the growing trend of "shifting upstream" in payment integrity within the healthcare insurance industry. Rather than focusing on recovering overpayments after claims are paid (a reactive, downstream approach), organizations are moving toward proactive prevention by detecting, validating, and making decisions earlier in the claims process—closer to claim intake and adjudication. The article argues that this prepay prevention model reduces costs, improves efficiency, and is becoming the new standard for payers and healthcare programs.
Source
bskyThe Shift Toward Prepay Prevention in Healthcare Payment Integrityhealthcareittoday.comKey quotes
· 3 pulledPayment integrity often lives at the end of the claims line, with teams measuring success by how much they can win back after payment.
That is why more organizations are now 'shifting upstream' in payment integrity.
This trend of shifting upstream or left means being proactive and moving detection, validation, and decisioning upstream, closer to claim intake and adjudication.
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