Rethinking pre-pay payment integrity for Blues plans

Why this matters

• The Blue Cross Blue Shield Association (BCBSA) is expanding pre-pay payment integrity (PI) requirements, with greater emphasis on pre-pay diagnosis-related group (DRG) review.
• Blues plans must manage the shift to upstream PI amid rising financial pressure on medical expenses.
• Cohere Health partners with Blues plans to build a flexible pre-pay model that evolves with your needs.

The industry is shifting away from post-pay recovery and toward upstream PI–identifying and resolving potential payment issues before claims are paid, eliminating the “pay and chase” model. That shift matters now more than ever, as Blues plans face growing pressure to manage medical expenses and improve operating performance. 

The five-step plan below works whether you're building a pre-pay DRG program from scratch or optimizing one already in motion.

1. Start with your current PI model

Start by mapping your current pre- and post-pay workflow program. Then pressure-test it:

• Claims selection: how are claims chosen for review, and how often do those reviews produce measurable findings?
• No-finding reviews: how much auditor time is focused on claims where the medical record supports the bill?
• Visibility: can auditors see why a claim was selected for review, and what documentation within the medical record supports the decision?
• Root causes: do billing trends and patterns identified in claims reviewed reach your provider conversations?

2. Make every review count

Focus auditor reviews on the claims most likely to yield findings, so every review moves your pre-pay operation forward. Cohere Health's AI-driven intelligent claims selection prioritizes claims with the highest probability of findings by automating the review of medical records where billing is supported, so auditors spend their time only on claims with findings.

The results:

• Up to 87% increase in auditor efficiency
• Up to 95% improvement in hit rate 
• 100% of auditors time spent on claims with findings

3. Choose the model that fits your plan

There's no one-size-fits-all pre-pay model. Cohere Health offers AI-powered end-to-end services, insourcing, and hybrid options. Every health plan has different needs. Some require end-to-end support across the full pre-pay workflow, while others prefer to bring operations in-house using technology that automates time-intensive tasks. Others find that a hybrid approach–blending internal capabilities, technology, and external support–works best. Cohere Health works closely with each plan to strike the right balance of people, technology, and operational support.

4. Build confidence into every decision

Cohere Health's transparent, clinically grounded AI technology shows auditors why a claim is selected for review, what documentation supports the determination, and where clinician review is needed, with appropriate clinician oversight throughout.

Understanding the patterns behind findings creates opportunities for targeted provider education and more informed, collaborative provider conversations.

5. Plan for what comes next

As PI programs mature, priorities and needs change. For host and home Blues plans, an effective pre-pay capability can support both fully insured (FI) and ASO membership, creating  opportunities to support other Blues plans and optimize the economics of their PI operations. Cohere Health stays closely involved as plans evolve their model, and continuously evaluates the economics of the pre-pay operation, with up to a 9x ROI.

Your move to optimize pre-pay

Plans that continue to optimize their pre-pay model will be best positioned for what's next.  Cohere Health starts with your current operations, moves quickly, and builds from there. Current Cohere Health clients can transition to a pre-pay model in as little as 2 weeks. For new clients, a pre-pay program can be up and running in just 8 weeks.

What's your pre-pay model?

What is your current PI model and the strategy for optimizing over time? Talk to a Cohere Health expert to assess your current pre-pay strategy and determine which approach makes the most sense for your plan.