How Pre-Payment Integrity Can Incentivize Evidence-Based Care

June 24, 2021 Gary Call, M.D.

Woman getting DEXA scan

How Pre-Payment Integrity Can Incentivize Evidence-Based Care

Brief anecdote here: DEXA scans are used to screen for osteoporosis and measure effectiveness of treatment. Current guidelines recommend that DEXA scans should not be used more frequently than every two years. Payers can use pre-pay editing to identify claims that vary from the clinical guideline recommended frequency and avoid paying for low value services. Messaging to providers allows them to align their practices with clinical guideline recommendations – improving the use of future healthcare resources while also avoiding a low value care payment in the present.

Following the Evidence

Evidence-based medicine, the practice of making clinical decisions based on the best available evidence as informed by research, clinical experience and patient values, is an important strategy in improving the quality and efficiency of care. Leveraging clinically and scientifically validated methods to guide decision-making, while taking into account the needs and desires of patients, leads to better health outcomes, lower costs and higher satisfaction.

Despite many years of focus on evidence-based medicine, there are still significant amounts of financial resources expended on care that does not provide value or improve outcomes. A review of research on waste in the US healthcare system in 2019 estimated that the annual cost of overtreatment or low-value care is between $75 to $102 billion.  Part of the problem is that payment incentives in the healthcare system are not always aligned with providers following evidence-based guidelines.

As with value-based reimbursement programs, in which payment is tied to quality and outcomes rather than quantity of services, attaching payment incentives to outcomes and performance may help encourage the adoption of evidence-based medicine among providers. Doing so prior to the point of payment can help to ensure providers are adhering to best practices and payers are avoiding unnecessary costs, improving care quality while reducing the amount of waste in the healthcare system.

Correcting Course

Integrating evidence-based guidelines with pre-pay payment integrity protocols not only helps to ensure claims are being billed and paid appropriately, but it also incentivizes providers to deliver services in the context of the pathway of care.

As in the example above, using pre-payment review processes avoids payments for low value care. It also provides an education opportunity and motivation to adhere to the guidelines going forward — ensuring the appropriate intervals between tests, properly coding the procedure or modifying protocols to align with evidence-based practices.

Putting Claims Into Context

Implementing a pre-payment analytics program can help your organization avoid improper payments and the administrative burden of recovering them. Choosing a solution that accomplishes all of this without having to request additional documentation from the provider can save your organization and provider network time, money and frustration.

At HMS, we are continuously pursuing new ways to help payers and providers streamline their payment integrity processes so that everyone can operate more efficiently. Visit to learn more about our pre- and post-payment integrity solutions, including our Episode of Care reviews that analyze claims in the context of the patient journey to identify discrepancies resulting in overpayment.

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