For decades, payment integrity in healthcare has been a mostly reactive game. Health plans historically focused on post-pay audits: correcting overpayments, chasing recovery dollars, and retroactively scrubbing claims data for inaccuracies. While this approach helped identify waste and reduce some financial leakage, it has resulted in processes that have been too late, too slow, and too costly.
But a major shift is underway.
Health plans are increasingly moving upstream in the claims adjudication lifecycle—a strategic pivot known as the “shift left” in payment integrity. This shift means rethinking when and how we identify errors, flag waste, and optimize payment accuracy. The future of payment integrity is proactive, and it’s happening pre-pay.
A Look Back: The Era of Post-Pay Dominance
In the traditional model, payment integrity largely existed after claims had already been paid. Plans relied heavily on retrospective reviews to catch inaccuracies such as:
- Billing errors (duplicate charges, upcoding)
- Coordination of benefits issues
- Non-covered services
- Incorrect application of contract terms
These reviews often happened months after services were rendered. The logic was simple: let the claim go through, then clean it up on the back end.
While this model helped recoup funds, it was inefficient. Overpayments had to be clawed back from providers—creating friction, delaying resolutions, and increasing provider abrasion. Worse, many improper payments went undetected or unrecovered due to limited resources, outdated systems, or lack of visibility.
Enter the Shift Left Movement
“Shifting left” in the context of payment integrity means moving error detection and correction earlier in the claims lifecycle, ideally before the claim is paid. The goal isn’t just to catch errors faster—it’s to prevent them from happening in the first place.
In software development, “shift left” refers to testing earlier in the process to catch bugs sooner. In healthcare, the same logic applies: the earlier you intervene, the less costly (and less damaging) the mistake.
This approach reframes payment integrity from a purely defensive tactic into a strategic initiative. Instead of playing financial whack-a-mole post-payment, payers are increasingly investing in tools and processes that embed intelligence into claims operations, bringing efficiency, accuracy, and speed to the forefront.
Why Pre-Pay Matters
There are several compelling reasons for payers to prioritize pre-pay payment integrity:
- Cost containment: Preventing overpayments is more cost-effective than recovering them. Not just because of the amount per claim recovered, but because of reduced admin costs.
- Administrative efficiency: Catching errors early frees up post-pay audit resources and reduces the administrative burden of rework.
- Member and provider satisfaction: Proactive accuracy reduces surprise bills and appeals, improving trust and reducing friction with providers
- Regulatory pressure: New rules around claims timeliness and transparency are pushing payers to streamline operations and demonstrate due diligence.
Challenges of Shifting Left
Of course, this transition isn’t plug-and-play. Moving payment integrity upstream comes with challenges:
- Data readiness: Real-time access to clean, structured, and normalized data is foundational. Many legacy systems aren’t built for that.
- Workflow redesign: Pre-pay workflows must be fast, accurate, and minimally disruptive. There’s little tolerance for delays in adjudication.
- False positives: Without finely tuned models, pre-pay systems can incorrectly flag claims, leading to delays and provider abrasion.
- Change management: Teams accustomed to post-pay methods must adapt to a more agile, real-time mindset.
Despite these hurdles, the industry is making progress—thanks in large part to emerging tools and technologies.
Tools That Support the Shift to Pre-Pay
Today’s health plans have a growing arsenal of tech tools to support a shift-left strategy. The most impactful solutions combine AI, machine learning, and rules-based automation to flag, prioritize, and route claims in real-time or near-real-time. Here’s what’s making the shift possible:
1. Data Normalization and Ingestion Platforms
You can’t automate what you can’t see. Smart ingest platforms unify disparate data sources (eligibility files, provider contracts, historical claims) into a usable format that enables fast decision-making.
2. AI-Powered Claims Review
Modern AI tools can ingest structured claims data, apply contextual rules, and compare claims against a growing knowledge base of payment policies, provider behavior, and historical precedent. These tools flag likely errors—like incorrect modifiers or coding inconsistencies—before the claim hits the payment system.
3. Smart Policy Enforcement Engines
Rather than relying on manual policy interpretation, pre-pay engines can automate enforcement of contract terms and clinical guidelines. These systems interpret lengthy documents (contracts, CMS guidance, payment policies) and apply them consistently and at scale.
4. Real-Time Integration with Adjudication Systems
The best pre-pay solutions don’t operate in isolation. They plug into existing adjudication platforms and work in tandem—injecting AI-driven insights into workflows without overhauling core infrastructure.
5. Feedback Loops for Continuous Learning
Effective pre-pay systems aren’t static. They rely on constant feedback from post-pay outcomes to retrain models, improve accuracy, and reduce false positives over time.
The Strategic Imperative
Shifting left is more than a technological upgrade—it’s a philosophical shift in how payment integrity is viewed. Instead of being a last resort to protect margins, it becomes a core capability that drives efficiency, supports providers, and reduces the total cost of care.
And it’s not an all-or-nothing game. The smartest payers are adopting a hybrid approach, combining targeted pre-pay interventions with smart post-pay validation to maximize impact across the claim lifecycle.
Looking Ahead
As cost pressures rise and provider networks grow more complex, shift-left strategies in payment integrity will move from “nice to have” to “must have.” Payers that act now—by investing in modern tools, redesigning workflows, and fostering trust between teams—will be better positioned to adapt and lead.
Because in today’s world of healthcare administration, shift happens—and it’s happening fast.
To learn more about how Machinify can help your health plan shift left, contact us today.
