Payment Integrity Transparency Evaluation Guide

This guide presents a framework for evaluating transparency in payment integrity (PI) programs for health plans. It addresses the challenges health plans face due to limited visibility into how savings are generated, validated, and measured. The document outlines the importance of transparency as PI operations expand across various workflows, including data mining and claims recovery. It categorizes PI vendors into three archetypes: Legacy Vendors, Merged Vendors, and Unified Intelligence Vendors, detailing how each approaches transparency. The guide identifies three core dimensions of transparency: detection, action, and performance. Each dimension is explained in terms of its significance in ensuring health plans can effectively manage findings, validate savings, and optimize program performance. The document also includes critical questions that health plans should ask their PI vendors to assess transparency and operational effectiveness. Overall, the guide emphasizes the need for clear visibility and understanding in PI processes to enhance decision-making and reduce dependency on vendors.