New framework assesses how far core payment accuracy functions have advanced as health plans set priorities for 2027
NASHVILLE, Tenn.--(BUSINESS WIRE)--Lyric, a healthcare decision intelligence company helping health plans make faster, more accurate, and more transparent payment decisions, today released “The State of Healthcare Decision Intelligence in Payment Accuracy,” a white paper that introduces a framework for assessing how far core payment accuracy functions have advanced. The paper argues that the next stage of payment accuracy is connecting decisions rather than automating more of them in isolation.
Today, a single claim can be flagged by several payment accuracy programs at once, each acting on its own. Every recommendation may be valid, but together they can lead to redundant reviews, record requests, and appeals that add cost and frustration for health plans and providers alike. Connecting those decisions helps health plans determine which action, or combination of actions, is most likely to produce the best outcome.
“Most payment integrity systems were built to answer whether an intervention is technically valid,” said Brian Berkowitz, Chief Product Officer at Lyric and author of the paper. “That will always matter, but a valid intervention that leads to an appeal, a record request, and a reprocessed claim may not have produced the best outcome for the plan or the provider. The next stage is giving health plans a clearer view of the best pathway for each claim and helping them learn from how their decisions hold up over time.”
“Healthcare decision intelligence” is becoming widely used across the industry, often without a shared definition. Drawing on more than 35 years of work with health plans, Lyric defines it by three conditions in practice.
- Expertise is in the software. Policy, data, rules, AI, workflow, and domain expertise operate as one governed system, maintained as the underlying evidence changes.
- Recommendations are traceable at decision speed. They return inside the live workflow and can be traced to the policy, data, and logic in effect when the decision was made.
- Human judgment stays central. The organization operating the system configures its rules and thresholds, tests changes before deployment, and keeps a person accountable for the final determination.
Where payment accuracy functions stand
Maturity in payment accuracy is often equated with automation. Lyric’s framework measures maturity differently. A highly automated rules engine that operates in isolation may be less mature than a system that coordinates multiple decisions, monitors outcomes, and improves over time.
Applied across core payment accuracy functions, the framework shows that how far a function has advanced depends largely on the kind of decision it makes:
- Pre-pay editing has moved furthest, because it is built on standardized data and codified policy. The most advanced approaches are beginning to coordinate interventions rather than apply edits one at a time.
- Data mining, coordination of benefits, record review, and fraud investigation sit in the middle. In these functions, technology increasingly finds and prioritizes opportunities while experts make the call.
- Subrogation relies most on human judgment, because its decisions turn on causality, liability, and legal expertise.
As functions advance, what changes is how health plans delegate work between their teams and technology. At earlier stages, people make the decision and technology supports them. At higher levels, technology executes defined decisions and coordinates across pathways, while people set objectives and guardrails and remain accountable for outcomes.
“As technology takes on more of the work, the question that matters most is who holds which decision rights,” said Yevgeny German, Chief Technology Officer at Lyric. “Mature systems make that allocation explicit. They define what technology executes, what it recommends, what data is used to make decisions, what requires approval, and what goes to an expert, and they give people the context and authority to step in. That is how health plans can advance without losing accountability for the outcome.”
A broader measure of performance
The paper describes how findings from audits and reviews can inform upstream controls. Over time, that can reduce the number of record requests and reviews needed, saving time for both health plans and providers.
For health plans setting 2027 priorities, the framework offers a common language for assessing where programs stand and what realistically comes next, function by function, and a way to measure progress beyond savings alone.
“The State of Healthcare Decision Intelligence in Payment Accuracy” is available at Lyric.AI/Resources
About Lyric
Lyric is the trusted leader in healthcare decision intelligence. Built on more than 35 years of proven results, Lyric combines AI with clinical, payment, and policy expertise to deliver transparent, auditable insights in milliseconds across real-time claims workflows. Lyric augments human decision-making so health plans can make faster, more accurate payments while maintaining full control. Today, Lyric supports 200 million lives, with nine of the top 10 U.S. health plans relying on its platform to reduce waste, improve efficiency, and support accurate payments. To learn more, visit lyric.ai.
Contacts
Media Contact:
Courtney Merolle
PR / Communications, Bospar
PRforLyric@bospar.com
