Get More From Your Existing Payment Integrity Programs, Vendors, and Data

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Payment Integrity is under pressure. Rising MLR, increasing coding intensity, and growing provider AI adoption are exposing the limits of today’s pay‑and‑chase, black‑box models. But most payment integrity programs still run on fragmented data, siloed workflows, and point solutions that make it difficult to see the full picture of your program or act in a timely fashion.

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Built on the Abacus Insights usable data platform for payers, the Abacus Payment Integrity Data Solution creates a connected, governed data foundation that helps health plans get ahead of rising MLR, increasing coding intensity, and growing provider AI adoption. Unify critical claims and non-claims data, detect overpayments earlier, reduce pay-and-chase, and scale into automation, analytics, and AI that produces measurable value over time.
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The Forces Reshaping Payment Integrity

Annual Improper Payments

Improper payments across U.S. healthcare programs exceed $100B annually, underscoring the need for earlier, data driven intervention.

Increase in Coding Intensity

Provider coding intensity has increased significantly over time, contributing to higher improper payments and increased downstream PI burden.

Coding & Billing Automation Spend

A large portion of provider AI investment is focused on coding and billing automation, accelerating how coding patterns and behaviors evolve.

Today’s Payment Integrity Reality

Payment Integrity teams are expected to catch more issues earlier, recover faster, and scale with fewer resources—but today’s tools make that nearly impossible. The result: PI teams stay reactive, spend more on contingency fees, and struggle to shift left.

How Abacus Solves These Challenges

Abacus delivers a secure, governed data foundation that unifies claims, member, provider, and clinical data—giving PI teams a trusted, longitudinal view instead of isolated transactions.

Richer data and configurable orchestration support more effective pre pay strategies—moving signal detection upstream without increasing false positives or provider abrasion.

Unified, insights ready data reduces manual reconciliation across vendors and workflows, accelerating recovery while improving consistency and defensibility.

Abacus supports hybrid PI models by making data, logic, and workflows visible and configurable—so payers can work across vendors and internal teams without black box dependency or data silos.

A governed, AI ready data foundation allows payers to adopt analytics and GenAI at their own pace—without disrupting existing systems or workflows.
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Ready to Modernize Your Payment Integrity Program?

Whether you’re supplementing existing vendors, shifting more PI in house, or preparing for AI enabled analytics and workflows, Abacus provides the data foundation to help you act earlier, move faster, and scale with confidence.

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Frequently Asked Questions

What is Payment Integrity and why does data matter so much?

Payment Integrity helps health plans prevent, detect, and recover improper payments across pre‑pay and post‑pay workflows. Abacus focuses on fixing the underlying data problem, giving PI teams a unified, governed view instead of relying on fragmented, claims‑only inputs.

How can payers shift left in Payment Integrity and do we need to replace our current vendors?

Shifting left requires earlier, richer context. Abacus sits in front of existing PI vendors, unifying claims, clinical, and provider data so payers can intervene earlier while continuing to leverage their current ecosystem.

Why do Payment Integrity programs struggle with transparency today?

Many PI programs rely on vendor‑owned logic and siloed outputs, creating black‑box decisions and mis-aligned incentives. Abacus restores visibility and control by making PI data usable and shared across vendors and internal teams from a single foundation

How does Abacus enable AI in Payment Integrity—without adding risk?

Abacus prepares PI data to be AI‑ready first, so analytics and GenAI can be applied safely and incrementally. This allows payers to adopt AI when and where it makes sense, without disrupting workflows or amplifying bad data.

Our Data Solutions

We focus on data solutions that power payer operations and initiatives

CMS Interoperability Compliance

Enables compliance with the Centers for Medicare and Medicaid Services’ requirements for interoperability for patient access

Risk Adjustment Performance

Unifies and delivers timely data for effective risk adjustment of government-sponsored plans to optimize care for high-needs members

Clinical Data

Integrates clinical, administrative, and health equity data into longitudinal member and patient records to provide a holistic view of the care journey

Total Cost of Care Management

Supports performance measurement and scaling of complex value-based and fee-for-service arrangements by providing current, complete, and accurate data

Stars Performance

Delivers insights-ready™ data for accelerating the best interventions for improving quality, outcomes and Star Ratings