Healthcare has been in a state of transformation for a while now. Just look at the tremendous advances continuing to impact clinical care or the emergence of innovative technology like AI in claims pricing. There is so much opportunity to build on this momentum and modernize the healthcare financial system.

One often-underrated tool to accomplishing that? Payment integrity.

Payment integrity creates more efficiency and other opportunities to improve healthcare. With a couple months of 2025 under our belts, we’ve taken time to reflect on a few trends within this space. Here are our thoughts on what we think will be important this year.

Prioritizing providers in payment integrity

We speak to payers daily at Zelis, and provider abrasion is always a top concern. Deploying a payment integrity strategy that puts the provider in the center can be transformational.

Increased transparency throughout the claims review process is a vital step to building trust with providers. By providing a clear view into how claims are processed, providers gain more insight that can help prevent disputes from even happening. By helping reduce the administrative time and energy providers have to spend on claims management, they can preserve more resources for patient care.

Fostering open communication and collaboration minimizes conflicts and facilitates solutions that address both parties’ needs. Payers can also help alleviate the documentation review process for providers by streamlining procedures and providing clear guidelines.

A shift toward blending of pre-pay and post-pay services

The U.S. spent $4.9 trillion in healthcare costs last year, and that’s projected to increase this year. Payment integrity strategies will be invaluable to helping payers lower some of these costs by ensuring that claims are paid correctly the first time.

More specifically, integrating pre-pay solutions and post-pay solutions can help payers reduce administrative waste and claim errors that account for nearly $100 billion of that spend. We’re already starting to notice this trend come to fruition – with an increasing number of payers shifting away from using a solely post-pay payment integrity solution to incorporating pre-pay as well.

This integration reduces waste and enhances the efficiency and effectiveness of healthcare payment systems. By catching claim errors before they are paid, payers can ensure payment accuracy from the start. What’s more, having a fully integrated capability to flow certain claims and outliers to post-pay creates an optimized program that ensures accurate payment with reduced administrative burden to all stakeholders.

The benefits only increase if you’re able to leverage claims editing as a primary or secondary line of defense. The ability to customize edits – or work with a partner who can – is immensely helpful too. That way payers can offer specific edits that align to their specific policy and help improve the accuracy of claims reimbursement.

Acceleration to address value-based care within payment integrity

Value-based care continues to be a focal point in our healthcare system, but it’s been hard to quantify. The complexity of this care model often leads to coding errors. In fact, 64% of medical coding experts have expressed concerns about whether current coding best practices can adapt to value-based care reimbursement models. What’s more, 29% believe it will be challenging to align existing systems with the stringent documentation practices required for value-based care.

Diagnosis-related group (DRGs) reimbursements can be a helpful solution to solve for this. Like value-based care, DRGs shift the focus from the quantity of services delivered to the quality and outcomes achieved. This aligns reimbursement with the specific care and treatment being provided. By effectively managing things like readmissions, outliers, transfers and other care outcomes, the value-based care model can be more readily measured.

Adopting AI in healthcare strategies across workflows

AI is a household name by now – and something nearly every organization is using in some form – but technology will never replace human expertise. Healthcare and patient care is personal, and it always will be. Removing a person from the review process is counterproductive. We must ensure AI in healthcare supports, rather than replaces, human expertise.

Not surprisingly, members agree. According to recent surveys by Talkdesk, 77% of consumers surveyed said they prefer speaking with a human regarding claims, even while being comfortable using AI chatbots for basic inquiries. 

Leveraging human experts and healthcare AI is crucial because it combines the speed and power of technology with the deep understanding and experience of human experts. AI can efficiently sift through large volumes of data to identify potential errors, but medical professionals — doctors, pharmacists, nurses, medical coders — are important to validate these findings.

This combination can offer a more thorough claims review process built on informed decisions. One more capable of handling the intricate and sometimes unstructured nature of data.

Staying ahead of the rapidly changing dynamics in healthcare – from healthcare AI and beyond – will require everyone to work together to improve efficiency, lower costs and gain more opportunities to prioritize patient care.

Learn more about how payment integrity solutions can help you do this by checking out our recent whitepaper or by reaching out to the Payment Integrity team.