Advancing payment integrity with real-time solutions

For a long time, payment integrity was structured around fixing problems after the fact. Post-payment reviews, audits and recoveries became necessary defenses against incorrect payments, but they also introduced their own challenges in the form of rework, delayed savings, administrative overhead and significant provider abrasion. 

From there, we began introducing prepayment interventions and flagging high-risk claims before adjudication. Today, we’re entering the next phase: payment precision.

Real-time error identification is what we at Optum call payment precision. It means we’re focusing on interventions that help ensure accuracy as a claim is being created, not weeks or months later.

We’re all in on solving problems before they even begin, so we’re using our scale, connectivity and analytics maturity to embed real-time intelligence directly into the claim lifecycle.

In practice, this reduces provider phone calls, appeals, rework and administrative waste across the health plan-provider ecosystem. Financially, it reduces administrative costs related to claim rework.

Operationally, it speeds up claim resolution. Strategically, it reduces friction with providers by helping them submit cleaner claims from the start. The value compounds when accuracy improves upstream, because every downstream process benefits from fewer exceptions.

It’s transformational. When payment integrity intelligence lives inside provider workflows, it creates transparency at the moment decisions are made. Instead of retroactive denials, providers receive guidance before submission, which significantly reduces avoidable errors. 

The closer intelligence is to the provider’s workflow, the more effective and sustainable prevention becomes. This is where payment integrity stops feeling punitive and starts functioning as a shared success model.   

When plan-specific intelligence is surfaced directly within provider revenue cycle workflows, it creates a shared, real-time decisioning environment. 

Scale matters here. Real-time prevention only works when connectivity operates across large networks of health plans and providers, and Optum leverages our footprint to modernize how information flows across the ecosystem. 

Real Edit Intelligence delivers health plan-specific edits in real time at claim submission, preventing noncompliant or incorrect claims before adjudication. This translates into meaningful administrative savings for both health plans and providers. 

Real Coordination of Benefits Intelligence determines coverage primacy by routing claims to the correct health plan the first time with near-instant response times. This helps reduce the burden on members to navigate complex health plan primacy rules. 

Additionally, health plans can integrate a broader suite of APIs and gain access to our provider network, which helps drive even more cost savings.

Many health plans are still constrained by legacy systems that can’t be modernized overnight. The key is prioritization. Payment integrity is a natural starting point for real-time solutions because it delivers both immediate financial impact and long-term operational value. 

Leaders should focus on moving upstream incrementally, aligning technology investments with provider engagement and operational workflows. Progress doesn’t require a full system overhaul, but it requires thoughtful integration where it matters most. 

The future is a fully integrated, end-to-end, real-time payment ecosystem. It will be proactive rather than reactive, connected rather than fragmented and precise rather than corrective. 

Payment integrity will no longer be about chasing errors after the fact. It will be about preventing them altogether and creating a better experience for both health plans and providers.

The next chapter of payment integrity is already being written. The competitive and operational advantage will belong to organizations that shift from recovery to prevention and embrace payment precision as a core capability.

Getting it right the first time isn’t just more efficient. It’s foundational to trust, scalability and sustainable value across the healthcare ecosystem.