Keep Up with Clearlink

A payment integrity vendor can show up with an impressive savings projection, a long list of edits, and a polished demonstration. Those materials only go so far in showing how the partnership will perform against your actual claims, policies, contracts, systems, and internal processes. Payment accuracy problems can come from many places. CMS reported an estimated Medicare Advantage improper payment rate of 6.09% for fiscal year 2025, representing $23.67 billion. CMS also notes that improper payments are not automatically fraud and can include overpayments, underpayments, insufficient documentation, or payments that otherwise fail to meet program requirements.

Mature risk adjustment programs rarely struggle because they lack data. More often, the problem is that different systems, vendors, and functions tell different stories about what happened to that data. For health plan and managed care organization leaders, the more useful question is whether the organization can explain the conversion from identified opportunity to accepted data to realized financial impact, including where and why that conversion breaks down.

A member with several months of high utilization is easy to flag. The harder and more valuable task is identifying a member whose risk is changing before the pattern becomes obvious through paid claims. That requires models capable of drawing from a broader mix of information, detecting movement across time, and separating actionable risk from expensive events that a care management program is unlikely to influence. AI can strengthen that process, but health plans still have to decide what risk they want to predict, how scores will affect work queues, which interventions correspond to each signal, and how member responses will feed back into future decisions. Without those connections, a more sophisticated score can become another data point competing for attention.

Healthcare analytics is much more than building another dashboard for basic reporting. For payer executives, it’s identifying the operational signals that consistently predict financial performance, member experience, quality outcomes, and regulatory performance before quarterly results arrive. To get the most value from healthcare analytics, health plans have to focus leadership attention on the handful of metrics that reveal where performance is improving, where risk is building, and where action can make the biggest difference.

Delays collect through intake errors, inconsistent workflows, documentation rework, competing priorities, unclear escalation pathways, or limited visibility into where cases are spending their time. Those issues can persist regardless of staffing levels. Still, aggressive efforts to accelerate case resolution can introduce new risks if documentation standards, review requirements, and oversight processes are not keeping pace. Here’s how to focus on reducing friction throughout the appeals and grievances lifecycle while maintaining consistency across every stage of review.

Most health plans have already worked through this year’s payment updates. The announcements have been analyzed. Budgets have been adjusted. Product teams have updated assumptions. Now they need to turn those assumptions into operational decisions. Review how payment pressures across Medicare Advantage, Medicaid managed care, and ACA markets are exposing gaps between contract design and contract execution, prompting health plans to reassess provider network operations and contracting in 2026.