By Jeffrey Snyder, Chief Administrative Officer, Penstock
When it comes to payment integrity (PI), health plans face unique challenges: tighter budgets, evolving regulations and the need for flexible solutions that can scale with growth. Selecting the right PI partner isn’t just about finding a vendor—it’s about finding one that meets your specific needs.
Enter the Goldilocks approach: identifying a partner that isn’t too big, too small, but “just right” for your organization.
Why Bigger Isn’t Always Better
Large PI firms may seem like the obvious choice due to their size and reputation, but they can present significant challenges for certain health plans. Their extensive resources and broad reach often come with trade-offs that impact cost, customization and service quality:
- Prohibitive Costs: Large firms often require significant upfront investments and provide rigid pricing models that strain some health plans’ budgets.
- Rigid Processes:It’s common for larger firms to rely on standardized processes designed for big clients. This lack of customization can result in inefficiencies and missed opportunities to address unique member populations or niche claims challenges.
- Lower Client Priority: Small to medium-sized health plans often take a backseat to larger, more lucrative clients—translating into slower response times and less access to resources when they’re needed most.
- Limited Transparency:Large firms sometimes provide aggregated or generic reporting, which makes it more challenging to pinpoint actionable insights and resolve systemic issues.
The Benefits of Emerging and Mid-size PI Vendors
Emerging and mid-size PI vendors are often better equipped to meet the needs of health plans. They combine agility, innovation and personalized attention to deliver tailored solutions that drive results.
Key advantages include:
- Cost-Effective Pricing: Their flexible pricing structures are designed to align with the claims volume and budgetary constraints of plans, ensuring affordability without compromising service quality.
- Personalized Attention: These firms prioritize relationship-building, often assigning dedicated teams and account managers who develop a deep understanding of the health plan’s unique needs and requirements. They act as an extension of the existing health plan team.
- Innovation and Agility: Emerging firms tend to adopt cutting-edge technologies and methodologies, allowing them to identify nuanced trends and address issues with greater precision.
- Proactive Problem-Solving: These vendors are more likely to engage directly with health plans to identify and address root causes, helping to resolve systemic issues rather than treating symptoms and benefiting from the same errors over and over again.
Key Criteria for Evaluating a PI Partner
Finding your Goldilocks partner is all about finding a balance that fits your specific needs. They should provide solutions that aren’t overbuilt for large systems or underpowered for critical challenges. Let’s dive into questions you need to ask when finding a partner that’s “just right” for your health plan.
How well do they understand your needs?
Look for partners who take the time to assess your health plan’s unique challenges, such as member demographics, claims complexities, regulatory requirements and provider-specific nuances. The best vendors don’t offer generic fixes—they design solutions tailored to your organization.
What do their reports tell you?
A great PI partner provides more than just numbers. Their reports should deliver actionable insights, including trends in claims, provider behavior and areas for improvement. Ask to see examples of their reporting to ensure it meets your standards.
Can they grow with your plan?
Whether your plan is growing membership or expanding service offerings, your PI partner should be able to adapt seamlessly. Can the partner scale their services without adding unnecessary administrative complexity or costs? Discuss their experience adapting to growth scenarios with other clients.
What results have they delivered for similar plans?
Proven expertise matters. Request case studies or references to confirm a vendor’s ability to achieve meaningful results, such as improving payment recovery rates or reducing errors.
Finding Balance: The Key to PI Success
Finding the right PI partner isn’t about choosing the biggest name or the lowest price—it’s about balance. A partner that understands your specific challenges, delivers actionable insights and grows with you can transform payment integrity into a strategic advantage.
Emerging and mid-sized firms often provide that ideal blend of innovation, flexibility and personal attention. By taking a “Goldilocks” approach, your plan can secure a partnership that drives sustainable success and stability for years to come.
