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The Agile Incubator Blog

Uncovering hidden opportunities to improve your payment integrity plan

Strategies for payers to recover more healthcare dollars

Would you believe that with all of the payment integrity challenges facing payers, there is no gold standard program available to address these issues?

It simply doesn’t exist in today’s marketplace, but the demand for this type of program is increasingly on the rise. The current mandate for health plans to remain profitable is driving the need for some real and immediate solutions. At Ajilitee, we have developed a Cost Containment Checkup to help our health plan clients do a deep analysis of their payment integrity programs. To begin this process, first take an honest assessment of the following:

  • Where are you?
  • Where do you want to be?
  • What are your capabilities by recovery area?
  • What do you need to do to improve?

Most plans can benefit from a similar process based on these key concepts: measuring, benchmarking, and maturity modeling.


To understand where you want to go, you need to understand where you are now. Starting with a baseline of the current state of your payment integrity program, you can better understand what your future goals should be and you can begin to strategize your path forward. First, you need to look across all of the different areas of cost containment (COB, claims review, eligibility, etc.) and conduct an unbiased assessment of your program. Look at vendor contingency fees, cost of internal resources, and outcomes. From there, calculate your return on investment for each area and each type of recovery entity. Don’t forget to measure current cost avoidance success as well. This number should factor into your overall results.


Results numbers alone don’t paint the full picture. At Ajilitee, we layer on industry benchmarking data to add further context to the plan’s financial results. Benchmarking compares the performance of one plan’s payment integrity program against a pool of other health plans of similar size on a low-to-high scale. Ajilitee’s proprietary database of benchmarks is based on extensive experience working with a large number of plans. Similar data will help you determine reasonable goals for your own plan and translate them into expected dollars. With this context, you can begin to map out potential growth areas for your organization.

Maturity modeling

Maturity modeling involves an assessment of all of the recovery areas to determine a level of effectiveness for each. When assessed across people, processes, and technology, this exercise gives you a clear snapshot of your best practices, illustrating where you’re performing your best and why.

Some capabilities that impact maturity include:

  • Whether all available data is being used to proactively identify and validate recovery opportunities
  • The technology (or lack thereof) to drive opportunity identification and case management
  • The accuracy, completeness, and availability of eligibility data across all areas
  • How well progress and results are being tracked and reported

Through this process, you will identify gaps in today’s processes, which will help you formulate plans for improvement. You may find opportunities such as moving recovery efforts into a lower cost channel, improving vendor contingency fees, and optimizing internal recovery teams.

Moving forward with an improvement plan

Armed with this deep analysis of your overall payment integrity program, you can outline improvements needed for each area and for your program as a whole. Identify your focus areas and priorities based on cost, level of effort, and value to the organization, and then map them out on a 3- to 5-year plan.

Partnering with Ajilitee

With Ajilitee as a partner, health plans can uncover hidden opportunities to optimize their payment integrity challenges. Our healthcare experts have deep experience in the payment integrity space, with years of experience in maturity modeling and benchmarking against industry standards. We have worked with a large number of health care plans to show them what’s possible in each of their recovery areas to drive them toward better profitability.