The visibility gap in payment integrity–and what it’s costing health plans

Ask a health plan executive about their cost containment program, and they’ll likely respond with a number–dollars recovered, claims denied, audits completed. While these metrics are tangible and important, they only tell part of the story. They show what happened, but rarely why it happened, which issues recur, or where the plan can actually intervene.

In that gap between output and understanding, billions of dollars in addressable waste continue to move through the system each year. The problem isn’t that health plans lack vendors, data, or analytics. It’s that most payment integrity (PI) programs were built to recover dollars, not to help plans understand why those dollars were lost in the first place.

Most payment integrity programs weren’t designed for transparency

In many organizations, PI didn’t evolve as a single, connected program. Instead, it developed over time through a combination of vendors, internal teams, point solutions, and retrospective workflows layered together across different parts of the organization.  According to a 2024 survey of health plan leaders, 90% of payers rely on two or more payment integrity vendors, forcing teams to manage multiple datasets, workflows, update cycles, and reporting structures across the payment lifecycle.

The result is fragmented visibility across a system designed to manage medical spend end-to-end. Today, many health plans still struggle to answer fundamental questions about how their PI programs actually operate:

• Why was this claim flagged?
• What rule, policy, or clinical rationale drove this finding?
• Is this an isolated billing issue–or a repeat provider pattern?
• Has this issue surfaced before across other workflows?
• Could it have been prevented earlier in the care journey?
• Is this something the plan can actually act on–or is it outside their control?

Without that clarity, programs remain reactive by default.

The visibility problem is structural

It's tempting to blame this lack of transparency on technology, believing that better dashboards, integrations, or AI could solve the problem. However, the issue runs much deeper. Visibility gaps often originate from underlying operating models, workflows, and incentives that define how internal programs and vendors are built and, consequently, how they operate.

1. Fragmented vendors mean fragmented visibility‍
   Most health plans rely on multiple PI partners across data mining, clinical validation, coding review, and recovery workflows. Each partner sees only a fraction of the claims ecosystem and operates with its own logic, reporting structure, and success metrics. Since no single entity manages the entire lifecycle, any broader insights across programs are accidental rather than intentional.
   
   This fragmentation creates environments in which the same issues surface repeatedly across workflows, but rarely connect back to a common root cause.
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2. Opacity protects recurring revenue
   ‍Many PI vendors operate on contingency-based pricing, where revenue is directly tied to recovered dollars. That model produces results, but it also shapes incentives. A vendor that helps a plan eliminate the root cause of an overpayment–whether that’s a policy gap, provider behavior, or system issue–may also reduce future recovery opportunities.In that structure, recurring findings can become economically favorable. Not because transparency is impossible, but because full remediation reduces the volume of future recoveries the model depends on.
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3. Operational silos slow adaptation and learning
   Even within health plans, people identifying payment issues often disconnect from the teams responsible for operationalizing changes. For example, in claims operations, analysts may identify emerging billing patterns or policy gaps, but implementing updates across rules, workflows, or claims systems can require multiple handoffs between business, IT, and vendor teams.
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4. Without explainability, findings can’t drive action
   Even when findings are surfaced, they often lack the context needed for action. A flagged claim, a recovery amount, or a summary report might be provided, but crucial details are frequently missing: what rule triggered the finding, which policy or logic it was based on, whether the issue is isolated or systemic, and if it connects to upstream clinical or authorization decisions.
   
   Without that context, health plans may know a payment issue exists, but still lack the visibility needed to prevent it from recurring. Without this clarity, programs are forced to remain reactive, rather than proactive.

Over time, these dynamics reinforce themselves. Programs with limited visibility tend to stay that way–not because plans don’t want more clarity, but because existing structures don’t create pressure or enablement to demand it.

The market is shifting from recovery programs to intelligence programs

The most significant shift in payment accuracy solutions is the change in what health plans expect their programs to deliver. While traditional recovery programs simply measure output, modern intelligence programs build capability. They don't just report what was found; they strengthen an organization's ability to understand and act on that information over time.

That means distinguishing:

• Recurring issues from one-time anomalies
• Provider behavior from policy-driven outcomes
• Actionable findings from operational noise

Not every payment issue can be eliminated. Some are driven by providers, others by contracts, and some lie entirely outside a health plan's direct control. However, without transparency, health plans cannot make these distinctions consistently–and without clarity, progress toward improvement stalls.

Why true visibility is becoming the new competitive advantage

As AI becomes more integrated into payment integrity, transparency has become essential. AI can accelerate payment integrity workflows at scale, but when plans lack visibility into how findings are generated, trust can erode and slow the adoption of the very technologies designed to help health plan teams operate more efficiently. 

At Cohere Health, we believe that the future of payment integrity depends on transparency, explainability, and connected operational visibility. That requires more than isolated point solutions–it requires a unified foundation that connects structured and unstructured data across claims, contracts, policies, benefits, and payment workflows. 

By creating a comprehensive data fabric across these, health plans can identify issues earlier, gain the context to act on them with confidence, and the intelligence to refine decision-making over time. The result is a payment integrity program that doesn't just recover dollars, but becomes more proactive with every interaction.

Learn how Cohere Health brings transparency and control to payment integrity.
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