Why Pre-payment Integrity Matters More Than Ever

The stakes for payment accuracy have never been higher. As claims become more complex and more costly, regulations evolve, and provider financial pressures increase; health plans must balance precision, efficiency and affordability. Every incorrect payment represents more than wasted dollars — it can add administrative cost and friction, and delays timely appropriate payment, ultimately affecting affordability for everyone across the healthcare system.

That’s why pre-payment integrity matters more than ever and why we’re especially proud to be named a Leader in Everest Group’s Pre-payment Integrity Solutions PEAK Matrix® Assessment 2026.

A year ago, Claritev was recognized as a Major Contender. This year’s advancement into the Leaders category reflects the progress we’ve made and validates the strategy we’ve been committed to for years — all of which is focused on delivering best in class value to our clients efficiently and at a competitive market price.

Why the market pressure is rising

For us, payment integrity has never been just about finding claim errors. Health plans are being asked to improve payment accuracy, reduce friction, adapt to changing regulations, and do it all with greater speed and confidence. That’s a much higher bar than it was even a few years ago.

In this environment, healthcare organizations can’t afford approaches that only recover dollars after payment or address only one part of the problem in isolation. Our comprehensive solutions are focused on helping clients make better decisions before inaccurate or fraudulent payments create downstream cost and friction.

Preventing costly mistakes that compound

Most payment integrity companies have a post-pay heritage, which requires recovery of inaccurate or fraudulent overpayment. Claritev has decades of pre-pay experience. That historical perspective matters because it impacts how you build the model and the solution to comprehensively address client challenges, and how you deliver competitively differentiated value to clients quickly. Too often, organizations are forced to choose between automation and clinical expertise or manage multiple vendors that each solve only part of the problem. We believe those tradeoffs should not exist.

Organizations can no longer afford disconnected payment integrity programs. By bringing pre-payment integrity, post-payment integrity, clinical review, analytics, and workflow together, we enable clients to move beyond a piecemeal approach to one that drives broader visibility and value.

Our strategy is built around a different philosophy: payment integrity works best when technology, responsible AI, clinical expertise, and operational insight work together, not independently.

While many payment integrity programs were designed to recover dollars after payment, Claritev has spent decades helping clients prevent wasteful payments before they happen. That perspective shapes everything — from how we apply AI and leading-edge technology investments to our clinical review process to the way we partner with clients and providers.

The scale and sophistication of our approach is reflected in the numbers. Evaluating more than 80 million code combinations allows us to identify increasingly sophisticated billing patterns before wasteful payments are made — helping clients better manage cash flow and prevent downstream appeals, rework, and unnecessary administrative cost. Our analytics continue to evolve, with 100 to 200 new factors added each month to address emerging billing patterns and coding complexities.

More than 300 payer clients rely on Claritev’s payment and revenue integrity services, because they need a flexible approach that combines automation, clinical expertise, and configurable client-specific policies, rather than forcing every organization into the same model.

Technology is powerful, clinical judgement is essential

Technology is powerful. But payment integrity isn’t simply a technology challenge. It’s also a healthcare decision-making challenge.

Some claim edits can and should be automated. Others require experienced clinicians and certified medical coders who understand the clinical context behind a claim and can distinguish between unusual billing and appropriate care.

That’s why our approach combines intelligent automation with physician-led clinical review. This approach helps to identify complex coding issues while reducing unnecessary provider abrasion and maintaining confidence in the decisions they make.

The result is speed with accuracy and high confidence. Approximately 97% of claims are returned immediately upon submission, while the remaining claims receive physician and certified coder review and are typically returned within 24 hours. That helps our clients improve payment accuracy without sacrificing operational efficiency.

But having the right model is only part of the equation. Delivering it consistently at scale takes operational excellence.

Operational excellence is the real differentiator

Claritev’s recognition as a Leader in Everest Group’s 2026 assessment isn’t the result of a single innovation. This achievement reflects years of disciplined execution and thousands of operational decisions — investing in clinicians alongside technologists, refining our analytics continuously, listening to clients, and building processes that scale without compromising quality, accuracy, and timeliness.

That operational excellence is what enables technology and clinical expertise to work together consistently, and at the speed today’s complex healthcare environment demands.

As Chief Operating Officer, I see that commitment reflected in the collaboration across our teams and in the discipline we apply every day to continuously improve — this is our primary focus because our clients depend on us to help them navigate increasingly complex payment decisions.

Improved payment integrity operations also support productive payer-provider relationships. Every unnecessary appeal, duplicate request, or inconsistent determination creates administrative burden, cost, and delays for everyone involved. Our experience supporting approximately 1.4 million contracted network providers, combined with decades of pre-payment expertise, gives us a unique understanding of how to improve payment accuracy while minimizing unnecessary provider abrasion.

It’s easy to think of payment integrity as a back-office function. But every payment decision ultimately affects someone. Accurate payments help reduce unnecessary administrative costs, support stronger payer-provider relationships, and contribute to a healthcare system that promotes affordability and predictability for the people who depend on it every day.

Recognition validates strategy, but our mission is larger

Being recognized by the Everest Group is an important milestone for our team. But more importantly, it demonstrates the client value that decades of investment in pre-payment integrity, deep clinical expertise, advanced analytics, and a commitment to helping healthcare organizations have had to improve payment accuracy before unnecessary costs and friction ripple throughout the system.

We’re grateful to our clients for trusting us, to our associates for making this recognition possible, and to Everest Group for acknowledging the progress we’ve made.

We’re proud of this milestone. And we’re even more excited about what comes next.