What is Payment Integrity? Payment Integrity is the process of ensuring healthcare claims are paid accurately, in the right amount, to the correct provider and for services that were authorized and actually delivered to a beneficiary. How can Context 4 Healthcare help your Health Plan achieve optimum Payment Integrity? We provide Health Plans with options from technical to complex payment edits, pricing and fraud, waste and abuse (FWA) detection for claim and payment accuracy, medical billing compliance, and pre and post payment auditing. Detection of inaccuracies in the claims adjudication process can occur prior to payment (pre-payment level) or after payment (post-payment level).
An optimal payment integrity solution can depend somewhat on the types of claims being processed, but basic technical edits should always be included here. Nearly all Commercial payers include some variation of quarterly updated Centers for Medicare & Medicaid (CMS) National Correct Coding Initiative (NCCI) edits. There are 3 types of edits; Procedure to Procedure (PTP) edits, Medically Unlikely Edits (MUE) and Add-on Code Edits.
Procedure to Procedure edits identify code pairs that overlap in terms of resources required to perform. Some or all work components involved in performing the first code would typically by duplicated if the same provider were to report the second on same Date of Service (DOS).
The second type of CCI edit is the Medically Unlikely Edit (MUE). Included with each CCI edit release is a list of CPT/HCPCS codes assigned an MUE utilization limit – the maximum units of service (UOS) reported for a HCPCS/CPT code reported by the same provider/supplier for the same beneficiary on the same date of service. Some Commercial payers generate their own MUE limits because their beneficiary pool does not match that of CMS, and/or because the commercial plan allows for different policy utilization limits than CMS does for some procedures. Edits appropriate to your Plan should be part of your technical edits applied to all claims.
The third type of edit is the Add-on Code Edit. A subset of both the American Medical Association (AMA) Current Procedural Terminology (CPT®) codes and CMS’ HCPCS codes are of the add-on code type. These groups of codes published quarterly is designed to be submitted on same DOS as a primary/parent code. We recommend editing claims to detect add-on codes submitted without an appropriate primary/parent code. There are many other types of technical edits. Health Plans should decide which apply to their claims and apply all appropriate claims to rigorous technical edits at the pre-payment level. In order for your adjudication system to accept claims in a format that can be clearly deciphered, document in your provider policies how you require claims be reported, and return claims that fire these edits to the provider and require they correct and resubmission errors, or appeal with support when they can defend a claim outside of typical parameters.
Editing claims technically is the first step towards payment integrity, but Health Plans must go further to detect fraud, waste and abuse (FWA) in today’s complex healthcare environment. FWA edits and reports are designed to detect anomalous claim patterns that have passed technical scrutiny. FWA edits should detect the most current patterns in claims data to identify high risk claim patterns. When FWA edits fire, medical records supporting the submission should be reviewed.
Some FWA claim patterns cannot be detected effectively by editing individual claims. FWA reports must allow for analysis of claims from certain sources, DOS ranges, subsets of claims from certain type of bill (TOB), place of service (POS), performing provider and/or referring provider association, specialty type association, etc., to isolate then study for FWA patterns beyond the claim level. An effective program integrity solution must provide the user with an array of FWA reporting tools for this purpose. The ability to compare frequency of reporting of specific services typical in the healthcare environment with an individual provider’s frequency of the same is just one example of a useful monitoring FWA reporting approach. There may be a valid explanation why a specific provider is performing a specific procedure three times the frequency of his/her peers, but such an outlier, if detected in a Health Plan’s claims data, warrants further investigation.
According to the U.S. Department of Health and Human Services (HHS) 6.6 percent ($28.8 billion) of the 439 billion dollars that Centers for Medicare & Medicaid Services (CMS) paid out in Calendar Year 2025 was determined to be improperly paid. This impropriety was attributed to inadequate documentation 63.2% of the time (insufficient 51.5% of the time, and no documentation at all 11.7% of the time), unsupported medical necessity (17.8%), and improper coding (10.8%). Your Health Plan’s statistics are unique, but they are not immune to this trend, which was expressed in the CMS 2025 Medicare Fee-for-Service Supplemental Improper Payment Data review.1
Payment Integrity involves protecting a Health Plan from paying inaccurately and sometimes for fraudulent claims. Technical edits, FWA edits and FWA reports are tools all Health Plans must optimize to suit their needs.
Context 4 Healthcare’s Medical Payment Integrity Solutions:
https://www.context4healthcare.com/solutions/medical-payment-integrity/
Context 4 Healthcare’s Dental Payment Integrity:
https://www.context4healthcare.com/solutions/dental-payment-integrity/
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