Payment Integrity: Cutting claim waste, lowering costs
Putting the right checks and balances in place at each stage of a claim’s lifecycle can help protect employees’ dollars and lower employers’ costs.
- A JAMA study found that 25% of health care spending is wasteful or unnecessary, making payment integrity — the discipline of ensuring employers only pay for care actually rendered — critical to controlling costs.1
- UnitedHealthcare's Payment Integrity program operates across 3 phases of the claim cycle (pre-claim, pre-pay and post-pay) to catch errors before, during and after claims are paid, ultimately paying 97.9% of properly submitted claims.2
- In 2025, the program generated $5B in savings for self-funded employers — averaging $375 PMPY — by touching roughly 21M claims and impacting approximately 12M plan participants.3
With health care costs rising, employers face a simple but critical question: Is every dollar they spend truly necessary and accurately billed?
A study published by the Journal of the American Medical Association (JAMA) underscores the importance of this question, finding that 25% of health care spending was identified as wasteful or unnecessary due to failure of care delivery or care coordination, overtreatment or low-value care, pricing failure, administrative complexity or fraud and abuse.1
Payment integrity is the discipline of answering that question — rigorously and consistently — so employers and their employees aren’t absorbing costs for services that were miscoded, duplicated or never truly delivered. The strength of that safeguard depends almost entirely on the carrier standing behind their plan. When claims are processed accurately the first time, cost leakage is caught before it reaches an employer’s bottom line or an employee’s bank account. When it isn’t, those errors quietly compound — and both employers and employees may pay the price.
That’s why the choice of carrier is so consequential. 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, do not contain missing or incorrect information, and are not duplicate submissions.2 Those claims move through a series of accuracy checks designed to catch errors before payment goes out the door.
The scale of that behind-the-scenes work is substantial. The UnitedHealthcare Payment Integrity program drove around $5B in savings for self-funded clients in 2025 largely through its robust, AI-enabled capabilities, creating a simplified claims processing experience and driving payment accuracy, quality and prevention.3 In 2025, the program touched roughly 21M claims and impacted approximately 12M plan participants — meaning about 6% of all claims from self-funded groups received a payment integrity intervention.3
When a carrier does that work well, employers and employees get what they should expect from their benefits: accurate claims, fewer frustrating experiences and savings that might otherwise have gone unrealized.
How UnitedHealthcare Payment Integrity solutions work
UnitedHealthcare Payment Integrity solutions proactively work to help lower the total cost of care for employers by reducing payment errors. Payment integrity works to help ensure that health claims are paid by the responsible party, using an end-to-end approach across all 3 phases of the claim cycle. Using this methodology, self-funded clients with UnitedHealthcare Payment Integrity solutions saved an average of $375 per member, per year (PMPY).3
| 1. Pre-claim | 2. Pre-pay | 3. Post-pay |
| Preventing issues before they start | Catching errors before payment goes out | Catching and recovering errors after payment |
| Pre-claim activity helps stop billing concerns before a claim is ever submitted. UnitedHealthcare verifies providers, gives real-time feedback on potential issues and guides better coding practices up front — helping to prevent fraudulent billing before it starts and helping providers get it right the first time. | Pre-pay helps catch and correct billing inaccuracies while a claim is being processed, before any payment is made. Automated edits check every claim against billing rules, smart analytics flag unusual claims for expert review and hospital and high-dollar claims are verified against medical records to make sure billing reflects the care actually delivered. | Post-pay helps catch inaccurate payments after a claim has already been paid, recovering dollars and feeding what is learned back into the system. Audits re-examine paid claims to confirm the right amount was paid, overpayment recovery returns dollars to the plan and analytics identify unusual billing patterns that point to fraud, waste or abuse |
Additionally, self-funded employers may be eligible for a lite or enhanced Coordination of Benefits (COB) program, designed to help uncover even more cost-saving opportunities. COB focuses on plan participant-level investigations to make sure the right insurer pays first, preventing duplicate payments and protecting plan dollars. The enhanced program features both pre-pay and post-pay analytics to identify other coverage, helping to ensure potential secondary coverage is detected before and after claims are processed. Other coverage identification flags when a plan participant has another health plan that should pay first, and eligibility outreach confirms coverage details directly with plan participants and through eligibility data exchanges to help keep records accurate.
Pre-pay investigations review members likely to have COB and set flags prior to the payment of claims, helping to prevent unnecessary payments. If a flag is set after claims are paid, the recovery team seeks reimbursement from the primary carrier to correct the payment. Payment order and recovery updates the primary payer on file to prevent future errors and recovers dollars on past claims paid in the wrong order.
Subrogation identifies when a third party is responsible for a plan participant’s injury or accident — shifting those costs onto the party who should be paying through pre-pay investigations and post-pay recoveries. Analytics flag claims where another party may be liable, specialists confirm the circumstances, plan participants are engaged and notified of the plan’s right to recover, and the responsible party or their insurer is pursued through negotiation and settlement to return dollars to the plan.
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