This is a guest article by Steve Sutherland, Senior Vice President of Information Systems at CERIS. Payment integrity is frequently positioned at the tail end of the claims process, where teams define success by the amount they can recover after payments have already been made. While recoveries are important, most payers and program leaders recognize the hidden costs of that approach.
That’s why more organizations are now “shifting upstream” in payment integrity. This shift upstream, or to the left, involves taking a proactive approach by moving detection, validation, and decision-making earlier in the process, closer to the initial claim submission and adjudication stages.
The objective is to identify and address problems earlier in the claims process—before payments are issued—when issues can be clarified, fixed, or resolved with minimal disruption. This initiative impacts the entire healthcare ecosystem. Large health systems and hospitals experience significant pressure when claim recoupments interfere with their revenue cycle strategies.
Group practices and solo practitioners alike face the burden of repeated record requests and recurring appeal cycles. Government agencies are under increased examination and must prove that their programs are operating with integrity.
