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Payment integrity teams are under unprecedented pressure that’s straining traditional pre-pay and post-pay controls:

Rising utilization
Increasingly complex benefit designs
Stricter compliance requirements
Accelerating provider innovation

But payment integrity cannot and should not carry the burden alone for delivering accurate, compliant claims payments.

Too often, payment integrity teams operate in silos, disconnected from other health plan functions whose work can materially impact affordability and cost management efforts. This is a missed opportunity.

Instead, health plans should look to align strategies and resources by bringing these complementary areas together — an approach illustrated by ancillary benefits management (ABM).

What is ancillary benefits management?

Ancillary benefits management (ABM) is an integrated operating model that focuses specifically on ancillary services, such as:

From a payment integrity perspective, ancillary services are important because they frequently represent an area of high spend, with high volume and billing practices that are evolving faster than legacy controls can adapt. Prior authorization processes for ancillary services also tend to be challenging.

The ancillary benefits management operating model helps manage these ancillary services by aligning:

Utilization management
Curated networks
Payment integrity

Network contracting works to build a network of providers or suppliers to deliver high-quality services at a fair rate.

Working in unison, networks and utilization management influence which services get ordered and where those service requests will be fulfilled. The goal is to deliver the right service from the right provider with the right documentation as efficiently as possible.

Once the service has been provided, payment integrity steps in to enforce what services were actually rendered. Payment integrity teams will evaluate if the claim was billed and coded correctly to determine if the claim should be paid.

How do health plans benefit from payment integrity alignment?

When complementary areas like networks, utilization management and payment integrity work together, it creates a fluid process that unlocks more value for health plans. Alignment helps to:

Reduce unnecessary utilization and spend in ancillary categories
Improve payment accuracy and reduce downstream recoveries
Create a more coordinated experience for members, health plans and providers

Another benefit to this approach is that it creates a feedback loop for continuous improvement of the entire process. Payment integrity functions like audits, clinical reviews or post-pay recoveries can identify changing billing behaviors, leakage patterns or other trends. These trends could help inform:

Future policy updates
Provider education opportunities
Utilization rules
Network actions

This feedback loop also helps payment integrity teams keep pace with an increasing demand for services. DME spend, for example, is projected to rise by $133 billion by 2033¹ and genetic testing spend is estimated to rise by $29 billion by 2032.²

As ancillary services continue to grow more specialized and data-sensitive, static payment integrity controls can quickly lose their effectiveness. The harmonization with networks and utilization management enables a more adaptive payment integrity model that evolves in real time, up-front before claims payment, rather than reacting after dollars have already been paid out.

What can health plans learn from the ABM model?

Payment integrity’s integration with networks and utilization management in ancillary benefits management is a powerful example, but it’s also a proxy for a broader operating truth. Health plans perform better when payment integrity is embedded as a strategic partner across functions, not positioned just as a downstream checkpoint.

The path forward is to treat ABM as a repeatable blueprint so payment integrity helps steer decisions upstream by:

Identifying high-leakage areas
Establishing shared metrics
Formalizing feedback loops

When payment integrity shares goals, data and governance with other teams, the health plan can prevent avoidable spend earlier, reduce provider abrasion and drive the most efficient care for members.

About Alex Berman, Vice President, Payment Integrity

Alex is a healthcare executive specializing in client engagement, product strategy and growth across payer markets. He partners with health plans to align client needs with innovative solutions that improve performance and continue to remove waste from the healthcare system.