# Payment Integrity * **Definition:** The process of ensuring that healthcare payments are accurate, timely, and compliant with regulations, minimizing fraud, waste, and abuse, while improving financial outcomes for healthcare payers. * **Taxonomy:** Healthcare Topics / Payment Integrity ## News * Selected news on the topic of **Payment Integrity**, for healthcare technology leaders * 2.2K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/23/2025 | [**Lyric Acquires ClaimShark to Expand Platform Value and Power Next-Gen AI Applications**](https://www.healthcareittoday.com/2025/05/23/lyric-acquires-claimshark-to-expand-platform-value-and-power-next-gen-ai-applications/) | [[Healthcare IT Today]] | | 5/20/2025 | [**Codoxo Creates New Point Zero Category in Payment Integrity: Pre-Claim Provider Education Reduces Abrasion While Saving Payers $12-16 PMPY**](https://www.prnewswire.com/news-releases/codoxo-creates-new-point-zero-category-in-payment-integrity-pre-claim-provider-education-reduces-abrasion-while-saving-payers-12-16-pmpy-302461019.html) | [[PR Newswire]] | | 5/20/2025 | [**Codoxo Creates New "Point Zero" Category in Payment Integrity: Pre-Claim Provider ...**](https://finance.yahoo.com/news/codoxo-creates-point-zero-category-220000925.html) | [[Yahoo Finance]] | | 5/8/2025 | [**ClarisHealth Enters into a Strategic Partnership with CoverSelf to Launch the First Fully Integrated Prepay Self-Service Solution for Health Plans**](https://www.prweb.com/releases/clarishealth-enters-into-a-strategic-partnership-with-coverself-to-launch-the-first-fully-integrated-prepay-self-service-solution-for-health-plans-302446939.html) | [[PRWeb]] | | 4/30/2025 | [**HealthEdge and Gynisus Bring AI-Powered Clinical Precision to Payment Integrity**](https://www.morningstar.com/news/business-wire/20250430919945/healthedge-and-gynisus-bring-ai-powered-clinical-precision-to-payment-integrity) | [[Morningstar]] | | 4/30/2025 | [**HealthEdge and Gynisus Bring AI-Powered Clinical Precision to Payment Integrity**](https://finance.yahoo.com/news/healthedge-gynisus-bring-ai-powered-130000220.html) | [[Yahoo Finance]] | | 4/23/2025 | [**ClarisHealth Reveals Key Operational Performance Benchmarks for Payment Integrity Programs**](https://www.prweb.com/releases/clarishealth-reveals-key-operational-performance-benchmarks-for-payment-integrity-programs-302434365.html) | [[PRWeb]] | | 1/30/2025 | [**Codoxo Welcomes Dr. Riccardo Baron as Vice President of Artificial Intelligence and Jim ...**](https://www.morningstar.com/news/pr-newswire/20250130ny08013/codoxo-welcomes-dr-riccardo-baron-as-vice-president-of-artificial-intelligence-and-jim-brady-as-vice-president-of-analytics) | [[Morningstar]] | | 1/13/2025 | [**New Mountain Capital close to acquiring RCM group Access Healthcare: media report**](https://www.fiercehealthcare.com/finance/report-new-mountain-capital-close-acquiring-rcm-group-access-healthcare) | [[FierceHealthcare]] | | 1/9/2025 | [**ClarisHealth Reinforces Position as Payment Integrity Technology Innovator for Health Plans with a Banner 2024**](https://www.prweb.com/releases/clarishealth-reinforces-position-as-payment-integrity-technology-innovator-for-health-plans-with-a-banner-2024-302345415.html) | [[PRWeb]] | | 12/21/2024 | [**Industry Revenue Insights and Market Worth with a Projected CAGR of 8.7or 2024 to 2031**](https://www.linkedin.com/pulse/exploring-medical-saas-system-market-industry-revenue-insights-zmsxf) | [[Linkedin]] | | 12/3/2024 | [**Cotiviti Welcomes Seasoned Technology Executive Suvajit Gupta as Chief Technology Officer**](https://www.businesswire.com/news/home/20241203139499/en/Cotiviti-Welcomes-Seasoned-Technology-Executive-Suvajit-Gupta-as-Chief-Technology-Officer) | [[Business Wire]] | | 12/3/2024 | [**Cotiviti Welcomes Seasoned Technology Executive Suvajit Gupta as Chief Technology Officer**](https://www.businesswire.com/news/beverlyhillschamber/20241203139499/en/Cotiviti-Welcomes-Seasoned-Technology-Executive-Suvajit-Gupta-as-Chief-Technology-Officer) | [[Business Wire]] | | 11/27/2024 | [**AI in Healthcare News and Updates**](https://www.healthitanswers.net/ai-in-healthcare-news-and-updates-112724/) | [[Health IT Answers]] | | 11/15/2024 | [**Transforming Payment Integrity with Generative Artificial Intelligence (GenAI): HealthEdge® and Codoxo Announce Strategic Partnership**](https://www.healthcaredive.com/press-release/20241115-transforming-payment-integrity-with-generative-artificial-intelligence-gen-1/) | [[Healthcare Dive]] | | 11/15/2024 | [**HealthEdge, Codoxo Partner for GenAI-Driven Payment Integrity**](https://hitconsultant.net/2024/11/15/healthedge-codoxo-partner-for-genai-driven-payment-integrity/) | [[HIT Consultant]] | | 11/14/2024 | [**Transforming Payment Integrity with Generative Artificial Intelligence (GenAI): HealthEdge® and Codoxo Announce Strategic Partnership**](http://www.businesswire.com/news/home/20241114558374/en/Transforming-Payment-Integrity-with-Generative-Artificial-Intelligence-GenAI-HealthEdge%C2%AE-and-Codoxo-Announce-Strategic-Partnership/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 11/14/2024 | [**Transforming Payment Integrity with Generative Artificial Intelligence (GenAI): HealthEdge® and Codoxo Announce Strategic Partnership**](http://www.businesswire.com/news/home/20241114558374/en/Transforming-Payment-Integrity-with-Generative-Artificial-Intelligence-GenAI-HealthEdge%C2%AE-and-Codoxo-Announce-Strategic-Partnership/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 11/14/2024 | [**Transforming Payment Integrity with Generative Artificial Intelligence (GenAI): HealthEdge® and ...**](https://www.businesswire.com/news/home/20241114558374/en/Transforming-Payment-Integrity-with-Generative-Artificial-Intelligence-GenAI-HealthEdge%C2%AE-and-Codoxo-Announce-Strategic-Partnership) | [[Business Wire]] | | 10/30/2024 | [**Codoxo Welcomes Ted Pitynski as Vice President, Head of Sales to Drive Growth for AI-Driven Payment Integrity Solutions**](https://www.prweb.com/releases/codoxo-welcomes-ted-pitynski-as-vice-president-head-of-sales-to-drive-growth-for-ai-driven-payment-integrity-solutions-302291732.html) | [[PRWeb]] | | 10/11/2024 | [**ClarisHealth Unveils Pareo® Partner Exchange: Revolutionizing Payment Integrity for Payers**](https://www.prweb.com/releases/clarishealth-unveils-pareo-partner-exchange-revolutionizing-payment-integrity-for-payers-302272738.html) | [[PRWeb]] | | 9/18/2024 | [**ClarisHealth Opens Registration for the Only Peer-Led Payment Integrity Conference**](https://www.prweb.com/releases/clarishealth-opens-registration-for-the-only-peer-led-payment-integrity-conference-302248750.html) | [[PRWeb]] | | 9/12/2024 | [**Health IT Business News - September 12, 2024**](https://www.healthitanswers.net/health-it-business-news-september-12-2024/) | [[Health IT Answers]] | | 7/11/2024 | [**AI Summit for Healthcare Payment Integrity Attracts Top Industry Leaders; Explores the Transformative Potential of AI in Revolutionizing Healthcare Cost Containment**](https://www.prweb.com/releases/ai-summit-for-healthcare-payment-integrity-attracts-top-industry-leaders-explores-the-transformative-potential-of-ai-in-revolutionizing-healthcare-cost-containment-302194429.html) | [[PRWeb]] | | 9/24/2023 | [**CEO of Optum's payment integrity to retire**](https://www.beckershospitalreview.com/disruptors/ceo-of-optum-payment-integrity-to-retire/) | [[Beckers Hospital Review]] | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Performant Healthcare**: A company specializing in technology-enabled payment integrity services for healthcare payers, focusing on identifying and recovering improper payments. - **Cotiviti**: A leader in payment integrity solutions, known for eliminating payment waste and providing comprehensive solutions for healthcare organizations. - **Alivia Analytics**: Expands payment integrity solutions to help healthcare payers reduce errors and enhance financial accuracy. - **Personify Health**: Offers an AI-driven health benefit navigation platform aimed at improving payment integrity. - **HealthEdge**: A healthcare technology company focused on enhancing payment integrity through integrated solutions. - **ClarisHealth**: A provider of payment integrity solutions, recognized for its Pareo® platform that enhances claims payment accuracy. - **Codoxo**: A company that has developed the Point Zero Payment Integrity model, focusing on proactive interventions to improve payment integrity. - **Solventum**: Formerly 3M Health Care, launched an AI-driven payment integrity solution to reduce claim denials. - **WellRithms**: A company recognized for its contributions to payment integrity and cost reduction in healthcare. - **Machinify**: A healthcare payment software platform being acquired by New Mountain Capital to enhance AI-powered payment integrity. - **Apixio**: Offers payment integrity solutions and has merged its business with The Rawlings Group and Varis. - **EXL**: A global data and AI company recognized for its innovative payment integrity solutions. - **New Mountain Capital**: Facilitated the merger of several payment integrity companies to create a technology-enabled platform. - **Performant Financial Corporation**: Awarded the New York State Medicaid Recovery Audit Contractor contract, specializing in payment integrity. ### Partnerships and Collaborations - **The Rawlings Group, Apixio Payment Integrity, and VARIS**: Merged to create a next-generation platform focused on enhancing payment accuracy and integrity. - **Valenz Health and Healthcare Bluebook**: Agreement to enhance healthcare outcomes through integrated member engagement and payment integrity solutions. - **ClarisHealth**: Launched the Pareo Partner Exchange to streamline vendor management and enhance payment integrity. - **AI for PI Community**: Hosted a summit to discuss AI adoption in the payment integrity sector, emphasizing collaboration. - **HealthEdge and Zelis**: Formed a strategic partnership to integrate systems for enhancing healthcare payment processes. - **ClarisHealth and CoverSelf**: A strategic partnership to enhance the Pareo® Partner Exchange, introducing a self-service prepay edit application integrated with a comprehensive payment integrity platform. - **Cotiviti 360 Pattern Review**: An AI-driven service combining prepay and postpay review processes to enhance fraud prevention. - **HealthEdge and Codoxo**: A strategic partnership to integrate HealthEdge Source with Codoxo's GenAI-driven Unified Cost Containment Platform to enhance payment integrity processes. - **PYMNTS and American Express**: Collaborated on a report identifying inefficiencies in healthcare payments and the potential for digital transformation. - **Senators and CMS**: Bipartisan group of Senators urging CMS to formalize payment pathways for algorithm-based healthcare services. - **Surescripts and Cleveland Clinic/Optum**: Collaborating on a pilot program to enhance prior authorization processes using AI. - **Sift Healthcare**: Collaborated with Solventum to transform denial prevention strategies from reactive to proactive. - **Concert**: Partnered with Availity to streamline prior authorization processes for genetic testing. - **ClarisHealth and Expion Health**: Strategic partnership to pre-integrate services into the Pareo platform, enhancing claims management and reducing costs. - **Hobson & Company**: Worked with ClarisHealth to validate the ROI of the Pareo® platform for health plans. - **Codoxo and Driscoll Health Plan**: Co-presenting at the NAMPI Conference to showcase AI solutions for healthcare cost management. - **3 Boomerang Capital and Enjoin, LLC**: Investment to provide strategic resources for enhancing technology-enabled capabilities in managing CDI and revenue integrity challenges. - **CHAI and ANSI**: Collaboration to develop certification frameworks incorporating ISO 17025 standards for Health AI. - **Rubrik and Microsoft**: Partnered to enhance data security for organizations using Microsoft Azure services. ### Innovations, Trends, and Initiatives - **Payment Integrity Mergers**: The merger of The Rawlings Group, Apixio's payment integrity business, and VARIS aims to reduce administrative waste. - **Proactive Payment Integrity**: The AI for PI Community's summit focuses on shifting from post-payment recovery to pre-payment accuracy. - **Power of Payment Integrity Conference 2025**: A peer-led event focused on payment integrity, featuring educational sessions and networking opportunities. - **Advanced Technology in Payment Integrity**: Performant plans to use advanced technology for post-payment assessments to rectify improper payments. - **ClaimInsight by AMPS**: A payment integrity platform that enhances accuracy and cost savings for payers and TPAs, utilizing a robust rules engine and physician-led expertise. - **Healthcare Payment Integrity Market Growth**: The merger of three companies aims to address the significant payment errors in the healthcare sector, estimated at $100 billion in improper payments. - **AI-Powered Payment Integrity**: New Mountain Capital's acquisition of Machinify aims to enhance capabilities in AI-driven payment integrity. - **HealthEdge Source**: A comprehensive payment integrity solution addressing chronic payment errors through contract modeling and proactive business intelligence. - **AI in Payment Integrity**: The integration of AI technologies is seen as a strategic tool to enhance payment integrity, improve claims processing efficiency, and reduce administrative burdens. - **Point Zero Payment Integrity by Codoxo**: A proactive model that intervenes before claims are created to reduce unnecessary costs and delays. - **AI and Machine Learning**: Increasing adoption of AI technologies in payment integrity solutions to enhance accuracy and reduce fraud. - **AI-Driven Solutions**: Codoxo's AI Data Health Integrity Agent automates data validation, improving efficiency in payment integrity. - **Cotiviti's 360 Pattern Review**: A new service designed to prevent and manage fraud, waste, and abuse throughout the claim payment cycle. - **Digital Transformation in Payments**: Healthcare organizations are increasingly pursuing digital solutions to streamline payment processes and improve patient experiences. - **Provider Data Management Systems**: The adoption of interoperability standards like FHIR and TEFCA to unify provider directory data and enhance payment accuracy. - **Clinical Documentation Improvement (CDI)**: Enjoin's pre-bill review solution aims to improve coding accuracy and revenue integrity, achieving significant ROI for clients. - **Virtual-First Healthcare Models**: Integrating patient data across care points to enhance data integrity and accessibility. - **Unified Cost Containment Platform**: Codoxo's platform that analyzes claims to detect issues and provide actionable insights for payment integrity. - **AI in Revenue Cycle Management**: The integration of AI and machine learning to automate claims processing, patient eligibility verification, and payment posting. ### Challenges and Concerns - **Data Quality Issues**: Inaccurate data can stall payment integrity initiatives, leading to financial losses. - **Fraud and Overpayments**: Healthcare payers face significant challenges related to fraud and overpayments, necessitating advanced solutions for payment integrity. - **Regulatory Changes**: Health plans are navigating complex regulatory environments that impact payment integrity efforts. - **Claims Processing Inefficiencies**: Current payment integrity processes are hindered by incomplete policy codification, imprecise claim selection, and lengthy review times, leading to provider burnout. - **Inefficient Payment Processes**: Over half of payment leaders express concern about delays in processing payments and claims, impacting financial stability. - **AI Adoption Barriers**: Many in the payment integrity sector are still in the early stages of AI adoption, hindering full realization of its benefits. - **Data Integrity and Compliance**: Concerns regarding patient safety, data integrity, and regulatory compliance in the adoption of AI technologies. - **DRG Revenue Integrity**: Challenges related to Diagnosis-Related Groups (DRGs) include increased downgrades and denials, necessitating effective data analytics and documentation. - **Billing Rule Variability**: Differences in billing rules among insurance payers complicate payment reconciliation and cash flow. - **Fraud, Waste, and Abuse**: Significant challenges in healthcare spending, accounting for up to 10% of total expenditures. - **Cybersecurity Risks**: Healthcare organizations face heightened risks when granting payers access to EHR systems, necessitating careful management of data sharing agreements. - **Claim Denials**: Over half of healthcare organizations cite claim denials as their greatest revenue cycle management challenge. - **Administrative Complexity**: Healthcare organizations face significant challenges related to managing fee schedules and insufficient IT resources. - **Administrative Costs**: Healthcare organizations face increasing administrative costs due to complex payment processes. - **Rising Denial Rates**: Healthcare executives are facing increased denial rates from payers, particularly in Medicare Advantage. - **Claims Denials**: The rise in claims denials due to the rapid implementation of AI rules for prior authorizations and medical necessity assessments poses challenges for providers. - **Compliance Risks**: Healthcare organizations face significant penalties for non-compliance with regulations like the No Surprises Act. - **Cybersecurity Threats**: Increasing cyber threats are prompting health plans to enhance security measures to protect member data. - **Staff Shortages**: Contributes to inconsistent documentation and revenue leakage, highlighting the need for effective retention strategies for CDI teams. ## Related Topics [[Data Integrity]]