Payment integrity: A fund’s hidden safeguard
Payment integrity catches claim waste before it drains fund reserves. See how layered checks across the claim lifecycle protect every bargained dollar.
For labor consultants advising multiemployer health and welfare funds, cost management has always been an exercise in protecting reserves while delivering meaningful care to a membership that spans decades of working life. Contribution rates are negotiated periodically and often lag cost changes, which means reserves must absorb cost fluctuations between bargaining cycles. Every dollar that leaks out of the plan — through a miscoded claim, a duplicate submission or a bill for a service never truly delivered — is a dollar those reserves can't recover.
A study published by the Journal of the American Medical Association (JAMA) found that 25% of health care spending was deemed wasteful or unnecessary, driven by failures in care coordination, overtreatment, pricing failure, administrative complexity and fraud and abuse.1 Payment integrity is the discipline of catching that waste — rigorously and consistently — before it reaches a fund's bottom line or a member's bank account.
The strength of that safeguard depends almost entirely on the carrier standing behind the plan.
Why carrier choice is consequential
When claims are processed accurately the first time, cost leakage is caught before it compounds. When they aren't, errors quietly accumulate — and both the fund and its members pay the price. A carrier with a mature payment integrity program operates a layered system of checks and balances behind the scenes: before, during and after claims are paid.
UnitedHealthcare, for example, ultimately pays 97.9% of all claims received for eligible commercial members when they are submitted in a timely manner, contain complete and correct information and are not duplicates.2 The remaining claims move through a series of accuracy checks designed to catch errors before payment goes out the door.
The scale of that work is substantial. In 2025, the UnitedHealthcare Payment Integrity program:3
- Drove $5B in savings for self-funded clients largely through AI-enabled capabilities
- Touched roughly 21M claims and impacted approximately 12M plan participants
- Applied a payment integrity intervention to about 6% of all claims from self-funded groups
- Generated an average of $375 per member per year (PMPY) in savings for self-funded clients
How payment integrity works in 3 phases
Payment integrity works across all 3 phases of the claim cycle to help ensure that claims are paid by the responsible party — and at the right amount.
Phase 1: Pre-claim. Before a claim is ever submitted, UnitedHealthcare verifies providers, gives real-time feedback on potential issues and support better coding practices — catching issues at the source.
Phase 2: Pre-pay. After a claim is submitted but before payment is issued, billing and coding inaccuracies are corrected through proactive monitoring. This helps reduce administrative costs, prevent incorrect claims from entering the system and avoid over- or under-payment — along with the costly, time-consuming corrections that follow.
Phase 3: Post-pay. If a payment is made in error, a retrospective effort — including data mining and review — helps understand why the error occurred, streamline the resolution process and reduce recovery turnaround time.
Coordination of Benefits: An added layer of protection
Funds may also be eligible for a lite or enhanced coordination of benefits (COB) program, designed to uncover additional cost-saving opportunities. The enhanced COB program features both pre-pay and post-pay analytics to identify other insurance, ensuring potential secondary coverage is detected before and after claims are processed.
- Pre-pay: Investigations review members likely to have COB and set flags prior to payment, helping prevent unnecessary payments
- Post-pay: If a flag is set after a claim has been paid, the recovery team seeks reimbursement from the primary carrier to correct the payment4
The bottom line for labor consultants
When a carrier does this work well, funds and their members get what they should expect from their benefits: accurate claims, fewer frustrating experiences and savings that might otherwise have gone unrealized. For consultants evaluating carriers on behalf of multiemployer funds, the maturity of a carrier's payment integrity program is not a secondary consideration — it is a leading indicator of how well reserves will be protected between bargaining cycles.
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