Latest eBook expands on how implementing payment accuracy models can reduce administrative burden and claims rework to support a more effective revenue cycle

JACKSONVILLE, Fla.: Availity, the nation’s largest health information network, today announced its latest industry resource, “Why Payment Accuracy Is the Next Operating Model for Payment Integrity.” This new eBook is intended to help healthcare organizations reduce downstream claims rework by shifting from reactive error management to proactive prevention.

According to the 2026 Availity Abrasion Index, payment integrity ranked as one of the top three most friction-inducing efforts for both payers and providers. With 64% of providers and 70% of payers rating it a 4 or higher out of 5, current payment integrity practices can create major abrasion, delay cash flow, and cause long-tail recoupment risks for providers. As administrative costs, denials, post-payment recovery, and payer-provider abrasion continue to rise, healthcare organizations need a more coordinated way to prevent avoidable issues before they enter downstream workflows.

To address the rising tension in the industry, payment integrity should evolve from adjudication and post-payment rework to a process that starts before a health plan ever receives a claim. Payment accuracy must shift from downstream correction to upstream prevention. The result is operational efficiency, improved speed, greater payment predictability, and reduced administrative costs. In addition, it results in improved member experience by reducing confusion or surprise billing.

“Appropriate and accurate payment is essential for every healthcare organization,” said Russ Thomas, CEO of Availity. “Too much effort is spent correcting payment issues after they have already created administrative burden for payers and providers. As an industry, we must shift work upstream so providers have clearer guidance earlier in the revenue cycle and payment integrity teams can focus on the complex cases where they deliver the greatest value.”

What is the difference between payment integrity and payment accuracy?

Payment integrity is intended to ensure that claims are legitimate, medically necessary, and financially appropriate. However, the current model is implemented through lookbacks or post-payment recovery, which costs both time and resources. Collectively, an estimated $25 billion is spent annually on claims adjudication, with $18 billion tied to reworked claims that ultimately get paid.

Payment accuracy moves the claims review process upstream, where administrative, clinical, and payer-policy guidance is applied before a claim is ever created. This model allows providers to identify and resolve avoidable issues in real time, reducing the volume of downstream rework and allowing payment integrity teams to focus on the complex scenarios where their expertise delivers the greatest value.

What does a mature payment accuracy model look like?

A mature payment accuracy model shifts the detection of common coding, clinical, and policy errors to before the point of submission. That allows payers to return clear, actionable edits to providers before the claim crosses the payer’s threshold.

Payment accuracy should embed payer-managed rules, clinical logic, and policy guidance directly into the provider’s claim submission workflow-before the claim reaches the payer’s systems. This model can identify eligibility issues, coding mismatches, contract misalignment, and documentation gaps in real time, enabling corrections before payment occurs.

Why should the healthcare industry shift from payment integrity to payment accuracy?

Payment integrity will continue to play a critical role in ensuring that claims are legitimate, medically necessary, and financially appropriate. However, it’s too often used to address preventable issues only after claims have already entered the payer system. That adds administrative burden and higher costs for everyone.

Payment accuracy focuses on prevention by addressing issues before claims are submitted, reducing costs and complexity. Payment accuracy shifts correction to the point where it is most effective-before submission-reducing avoidable rework, lowering administrative costs, and minimizing friction across the ecosystem. In doing so, it allows payment integrity to operate at its highest value: managing complexity, not cleaning up preventable errors. It also gives providers clearer guidance before submitting a claim, so they can focus more on patient care and less on administrative tasks.

What should payment integrity teams focus on if payment accuracy is successful?

In an ideal state, payment integrity teams focus on high-value activities: analyzing complex medical claims, identifying and addressing fraud, waste, and abuse, and partnering with medical policy teams to define and enforce appropriate payment rules.

What role does AI play in denial prevention?

AI can help improve claims and the submission process by enabling the early identification of claim errors, allowing providers to prevent avoidable denials and reduce administrative burden at scale. Specifically, it will help organizations:

• Predict recurring sources of error earlier in the lifecycle
• Deliver real-time, actionable guidance to providers
• Identify patterns in errors and help teams prioritize fixes

How does Availity support payment accuracy?

Availity combines network scale, payer connectivity, claims intelligence, and predictive analytics to enable real-time exchange for processes including eligibility, authorizations, claims, clinical information, and more. Through this network, payers and providers have tools to surface valuable insights that can reduce abrasion between parties.

Where can healthcare leaders learn more?

Download the eBook: “Why Payment Accuracy Is the Next Operating Model for Payment Integrity.”

About Availity

Availity empowers payers and providers to deliver transformative patient experiences by enabling the seamless exchange of clinical, administrative, and financial information. As the nation's largest real-time health information network, Availity develops intelligent, automated, and interoperable solutions that foster collaboration and shared value across the healthcare ecosystem. With connections to over 95% of payers, more than 3 million providers, and over 2,000 trading partners, Availity provides mission-critical connectivity to drive the future of healthcare innovation. For more information, including an online demonstration, please visit www.availity.com or call 1.800.AVAILITY (282.4548). Follow us on LinkedIn.

Fonte: Business Wire