Get the facts: What is payment integrity?
Open a newspaper, turn on the nightly news, or scroll through your social feed, and you’re likely to come across conversations about the challenges facing our health care system. These conversations are important, but they’ve also revealed there’s a lot of confusion about health care, and for good reason – it’s very complex.
In this series of articles, we’re setting out to debunk some of the most common myths and misconceptions about health care and health insurance. Our goal is to clear up the confusion and provide the facts about how the health care system works so we can identify solutions to make it better.
Health care affordability is one of the most pressing challenges facing Americans today. Medical costs have consistently outpaced inflation,1 and according to CMS projections, U.S. health care spending grew by more than 8% in 20242 — nearly 3 percentage points faster than GDP. Health care is expected to consume 20% of the economy by 2033.
What makes these stats even more concerning is that nearly a quarter of all health care spending is considered wasteful3 — driven in part by billing errors, inefficiencies and fraud.
At UnitedHealthcare, we believe that every health care dollar should be spent wisely. That’s why we’re introducing a series of new initiatives designed to help:
- Eliminate unnecessary costs created by billing errors, waste or fraud
- Align payments with the care that’s actually delivered
- Improve the accuracy of payments across the health care system
These initiatives are foundational to building a more affordable and sustainable health care system while reducing the cost burden for our members and customers.
What is payment integrity?
UnitedHealthcare’s payment integrity initiatives are estimated to generate around $1.5 billion in cost share savings for UnitedHealthcare members in 2025.
Payment integrity operates similar to a bank’s fraud prevention and transaction verification systems. Just as banks monitor transactions to protect account holders from errors or misuse, payment integrity teams work behind the scenes to ensure that claims are paid correctly, efficiently, and in compliance with policies and regulations.
This includes:
- Verifying that services billed match those provided
- Preventing duplicate or erroneous claims
- Identifying and addressing potential fraud, waste and abuse
- Ensuring that reimbursement aligns with industry standards and contractual agreements
Importantly, payment integrity reviews occur after health care services have been provided to ensure claims are paid accurately and fairly, consistent with the services delivered. Additionally, these reviews do not impact a member’s care or coverage, which are determined by the member’s benefit plan.
RELATED: How UnitedHealthcare Payment Integrity solutions work
Why payment integrity matters
When claims are paid inaccurately, the consequences ripple across the system. Employers and plan sponsors may face higher premiums. Members may pay more out-of-pocket. And providers may experience delays or denials that erode trust.
The UnitedHealthcare payment integrity initiatives are designed to:
- Lower costs for patients by reducing unnecessary spending, helping to keep premiums and out-of-pocket expenses as low as possible.
- Promote integrity and fairness by aligning reimbursements with the services rendered, ensuring that everyone is treated fairly.
- Improve transparency so that patients and providers know what to expect and understand how and why payments are made.
What is the real-world impact of payment integrity?
We’ve identified instances where some providers are billing separately for certain services in an inpatient hospital setting — such as newborn hearing screenings — that should be included in the overall bill from the hospital. This practice can result in members being billed twice for the same service by both the facility and provider, forcing our members to pay out-of-pocket for care twice. To address this, we updated our reimbursement policy to ensure services are paid in alignment with where they are typically and appropriately delivered and to the right provider of care.
These changes translate directly into lower out-of-pocket expenses for patients and a more sustainable health care system overall.
Our commitment to creating a better system
At UnitedHealthcare, we are stewards of our members’ and customers’ health care dollars. Just as a bank safeguards your finances, we are committed to protecting your out-of-pocket health care costs. Through these initiatives, we aim to build a system that is not only more efficient but also more equitable, transparent and affordable for all.
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