Preventing an inappropriate claim from being paid in the first place versus recovering an overpayment after the fact is always the ideal approach for health plans—but in many cases, this simply isn’t possible. For example, identifying fraud or abuse typically requires health plans to retrospectively analyze patterns of paid claim behavior to identify the aberrance, and high-dollar, complex claims often can’t be fully analyzed prepayment while still meeting prompt-pay requirements. Therefore, the most successful plans take a measured, thoughtful approach to moving payment integrity concepts from retrospective to prospective—while ensuring their prepay and postpay programs share information with each other as efficiently as possible to optimize the payment integrity cycle.
