Six Evolving Trends Reshaping Prepay Claim Editing and Payment Integrity
By Mike Spellman, Senior Director of Consulting Solutions, Lyric
As healthcare spending is projected to reach $7.7 trillion by 2032, payment accuracy will become more critical than ever before. Through our work with leading health plans at Lyric, we've identified six transformative trends that will help reshape how organizations approach prepay claim editing and payment integrity. These innovations will revolutionize how health plans process claims, interact with providers, and deliver value to their members.
AI and Advanced Analytics: The New Frontier of Payment Accuracy
The integration of artificial intelligence and advanced analytics into prepay claim editing will represent a fundamental shift in how health plans approach payment accuracy. Expect tomorrow's sophisticated AI systems—keeping humans in the loop—to go beyond traditional rule-based editing, offering predictive capabilities that will speed up detection related to cost-of-care trends, as well as transform how plans prevent payment errors before they occur.
What will make this trend particularly powerful is for plans to more quickly process and act upon vast amounts of complex healthcare data in real-time. Modern AI systems will analyze intricate patterns across millions of claims at an accelerated rate, identifying subtle anomalies that might indicate potential issues. This predictive capability will enable health plans to move from reactive error detection to proactive error prevention.
Sophisticated AI models will also increase accuracy in real time for solutions that focus on targeting specific types of claims. The ability to learn and refine selection criteria will improve efficiency while reducing cost and provider abrasion. This will be achieved by AI capability analyzing selection criteria against review outcomes, rebills, and adjustments—to improve performance and outcomes.
The impact will extend beyond mere accuracy. These systems will understand complex clinical scenarios, evaluate medical necessity in real-time, and help predict potential fraud patterns before claims are paid. This technological leap will mean health plans can intervene far sooner—dramatically reducing the need for costly post-payment recoveries and provider abrasion.
Regulatory Agility: Building Compliance into the Core
In tomorrow's dynamic regulatory environment, success in prepay claim editing will require unprecedented adaptability. Forward-thinking health plans will leverage flexible editing systems that can incorporate clinical content and updates from CMS, AMA, and other governing bodies with little impact on existing workflows—including state based content.
This agility will extend beyond mere compliance. Leading organizations will leverage their prepay editing systems to align with evidence-based guidelines and plan-specific policies, creating a more cohesive approach to payment accuracy. This will help plans avoid costly penalties while ensuring consistent application of policies across all claims.
The most innovative plans will build regulatory intelligence directly into their editing platforms, enabling real-time updates and automated policy alignment. This approach will not only ensure compliance but transform regulatory changes from potential disruptions into opportunities for process enhancement. This will include transparency into clinical content for providers creating a cohesive approach to deploy, manage and measure policy adherence.
Reimagining Provider Collaboration
Perhaps the most transformative trend will be the evolution of provider relationships through enhanced prepay claim editing processes. Claims editing will no longer be viewed solely through the lens of cost containment. Tomorrow's solutions will prioritize transparency and collaboration with providers.
Modern systems will offer intuitive interfaces that give providers immediate access to claim decision information and clear explanations for edits. This transparency will help reduce provider abrasion – a crucial consideration for health plans looking to maintain strong provider networks. By enabling providers to understand and correct potential issues before claims are submitted, plans will significantly reduce the administrative burden and unlock greater value for both stakeholders.
This collaborative approach will extend to educational initiatives, where health plans will share insights on common billing errors, rules and policies used, as well as providing real-time guidance on proper coding practices. The result will be a more efficient claims process that benefits payers, providers, and patients. If providers have insight into policies and guidance it can create an opportunity where providers reduce services that are not necessary which can also drive down cost and improve patient outcomes.
Integration: Breaking Down Organizational Silos
A fundamental shift in payment integrity strategy marks the fourth major industry trend. While many Payment Integrity (PI) departments currently operate in isolation—sometimes even maintaining separate pre- and post-payment divisions—the most successful programs are taking a different approach. Organizations achieving both cost reduction and increased savings are breaking down these silos, strategically integrating PI functions across their entire enterprise.
The future of Payment Integrity (PI) is evolving toward a seamless integration of pre- and post-payment capabilities. Traditional post-payment functions, like Coordination-of-Benefits (COB), are increasingly migrating to the pre-payment environment. This shift not only enhances savings but will also help to streamline operations and reduce friction among payers, providers, and patients. The industry is moving from retrospective and batch-based solutions to real-time response measurements when managing coverage primacy and overpayment identification.
Leading Payment Integrity Teams are taking this integration further by investing in platform-based models that transcend traditional departmental boundaries. These innovative capabilities enable enhanced cross-departmental collaboration, improved provider partnerships, greater data sharing, and more accurate claim processing. The focus has shifted to leveraging shared resources across the organization.
For instance, Special Investigation Units (SIU) can now monitor provider claims without immediate denial actions, thanks to advanced analytics tools that process claims in parallel and generate comprehensive provider impact reports. These features, built into modern PI solutions, allow healthcare plans to eliminate redundant work, reduce costs, and achieve more effective outcomes through cross-departmental utilization.
The Promise of Large Language Models
The emergence of Large Language Models (LLMs) in healthcare payment integrity will mark one of the most significant technological leaps in prepay claim editing. While traditional automation has focused on rule-based systems, LLMs will revolutionize how health plans process and understand complex healthcare documentation.
What will make this technology particularly groundbreaking is its ability to analyze and interpret the massive volume of healthcare policies and guidelines that change annually. Today's health plans face the challenge of reviewing hundreds of thousands of documents that change each year – with typically 20-25% of policies updating annually across state, federal, and organizational levels. LLMs will transform this process by automatically downloading, analyzing, and extracting relevant information from these documents, reducing policy review times from months to weeks.
AI Co-Pilots will serve as intelligent assistants embedded within existing workflows, enhancing human capabilities without disrupting established processes. They will analyze policies, guidelines, and patient data in real-time, providing contextual insights that help streamline decision-making. For complex areas like genetic testing, where there are over 175,000 available tests and approximately 800 CPT codes used in nearly 2.2 million unique code combinations, LLMs will offer unprecedented clarity by providing clear, contextual explanations of coding requirements and medical necessity criteria.
The impact will extend beyond mere efficiency gains. These systems will enable health plans to provide non-technical, plain-language explanations for claim decisions, helping reduce provider abrasion and improve member satisfaction. By combining human expertise with data-driven intelligence, LLMs will help health plans navigate the increasing complexity of healthcare payment integrity while maintaining accuracy and compliance.
Prepay Editing Through a Lens of Value-Driven Payment Integrity
Another trend to watch for will be health plans shifting from a traditional cost-savings mindset to a value-driven approach in prepay claim editing. This fundamental change will redefine how success is measured and achieved in payment integrity programs.
An evolution will move beyond simply identifying and preventing payment errors, tomorrow's prepay claim editing systems will play a crucial role in unlocking greater value across the entire healthcare ecosystem. Instead of measuring success solely through savings metrics and overturn rates, watch for more health plans adopting more comprehensive measures that include clinical outcomes, reduction in unnecessary services, provider satisfaction, and administrative efficiency. Incentive models with plans and with providers will also shift to help plans promote and drive changes.
Be on the lookout for technology that will enable health plans to identify opportunities for intervention before claims arrive. Advanced analytics will help identify high-risk members who might benefit from proactive care management, potentially preventing costly emergency room visits and reducing overall medical spending. Provider collaboration will also be transformed under this value-driven model, with health plans sharing insights and analytics to help improve coding accuracy and reduce unnecessary services.
The success of this shifting approach to value will rely heavily on the integration of claims data with clinical information, enabling health plans to make more informed decisions about medical necessity and appropriate care pathways. This holistic view will help ensure that payment integrity efforts align with quality care delivery and optimal member outcomes.
Looking Ahead: The Future of Prepay Claim Editing
As we look to the future, these trends will continue to shape the evolution of prepay claim editing. Success will lie in selecting solutions that not only address current needs but can adapt to future requirements. This will mean investing in flexible, scalable systems that can grow and evolve with your organization.
At Lyric, we'll remain committed to helping health plans navigate these trends and implement solutions that drive real results. The future of prepay claim editing won't just be about catching errors – it will be about creating a more efficient, transparent, and collaborative healthcare payment ecosystem.
For payment integrity leaders, these trends will present both challenges and opportunities. The key to success will lie in viewing these innovations not as disruptive forces but as tools to enhance payment accuracy, improve provider relationships, and drive operational efficiency.
By leveraging these innovations and choosing the right technology partners, health plans will transform their payment integrity, ultimately contributing to a more sustainable and effective healthcare system for all stakeholders.
About Lyric
Lyric, formerly ClaimsXten, is a leading AI healthcare technology company, committed to simplifying the business of care. Over 30 years of experience, dedicated, expert teams, and top technologies help deliver up to $14 billion of annual savings to our many loyal and valued customers—including 9 of the top 10 payers across the country. Lyric’s solutions leverage the power of machine learning, AI, and predictive analytics to empower health plan payers with pathways to increased accuracy and efficiency, while maximizing value and savings. Lyric is investing in AI driven technology to ease implementation and speed to value for customer savings, while offering enhanced and newly available solutions through internal product development and strategic partnerships, including recently announced partnerships with Concert Genetics, Autonomize AI, and now, Codoxo. Discover more at Lyric.ai.
