Payment Integrity as a Trust Problem, Not Just a Financial Problem

When most healthcare actuaries think about payment integrity within payers, they treat it as a financial exercise, making sure claims are paid correctly, at the right time and right price, reducing waste, and preventing fraud. While those are essential outcomes, framing payment integrity purely as a cost-control measure misses the deeper issue and breeds mistrust.

Mistrust is far more corrosive than overpayment. It erodes relationships, drives inefficiency, and undermines the very affordability these programs are meant to protect.

At its core, payment integrity is about trust between payers, providers, and patients.

Without trust, the financial machinery of healthcare becomes adversarial, inefficient, and ultimately harmful to everyone it serves.

Financial Lens: Necessary, but Narrow

Health insurers spend billions annually on payment integrity programs — rules engines, audits, fraud detection, and claims repricing and reviews. The financial rationale is clear: without these controls, overpayments and abuse can erode margins, inflate premiums, and threaten sustainability and affordability.

But the financial lens is limited. Focusing only on recoveries, savings, and error rates turns payment integrity into a scorecard of who won and who lost.

Providers see audits as clawbacks; Patients see denials as barriers to care; and Payers see controls as defensive shields.

What’s missing is the recognition that payment accuracy should strengthen relationships, not strain them.

Trust is the Real Currency

In my experience as a product and engineering leader at Microsoft, and now as the founder of Nedl Labs, I’ve seen that technology alone doesn’t solve systemic problems — trust does. You can build the most advanced AI, the most efficient workflows, or the most secure systems, but if the people using them don’t trust the process, the outcomes, or the fairness behind it, the system fails.

• For Providers: When claims are denied or reworked without transparency, providers lose trust in the payer. Administrative burden increases, relationships sour, and care delivery is disrupted.
• For Patients: When billing errors or denied claims trickle down to patients, they lose trust in both the insurer and the system itself. Unexpected bills create financial anxiety and distrust in healthcare affordability.
• For Payers: Without trust, payers find themselves locked in costly cycles of disputes, appeals, and oversight that drain resources and goodwill.

The objective measure of payment integrity isn’t just dollars saved — it’s whether payers and providers trust each other enough to collaborate instead of contest.

The Role of Transparency

Trust is built on clarity and fairness. Today, too much of payment integrity happens in black boxes — complex policy manuals, opaque coding rules, and fragmented workflows. Providers don’t always know why a claim was denied. Patients rarely see how coverage determinations are made. Even payers struggle to keep up with evolving regulatory and contractual requirements.

What’s needed is intelligence with transparency:

• Policy and contract terms that are machine-readable and consistently enforced.
• Claims decisions that come with clear explanations, not just codes.
• Feedback loops where providers understand how to submit correctly the first time.

When transparency is embedded in the process, payment integrity shifts from punitive to preventive — from fixing mistakes after the fact to getting it right the first time.

How AI Can Help - Responsibly

AI is not a silver bullet, but it can help payers scale transparency if implemented responsibly.

• Natural Language Processing (NLP): to parse dense payer policies and contracts into structured, usable rules.
• Machine Learning: to identify patterns of errors or abuse proactively, before they snowball.
• Generative AI: to explain policy and coding decisions in plain language, building understanding instead of frustration.

But AI must be implemented with guardrails: fairness, explainability, and auditability are non-negotiable. Without them, AI risks reinforcing mistrust instead of repairing it.

AI without explainability, fairness, and auditability risks deepening mistrust. Payers must use AI to illuminate, not obscure.

From Savings to Stewardship

The real future of payment integrity is moving beyond “savings recovered” to stewardship of trust and resources. Imagine a system where:

• Providers trust that claims will be paid accurately and on time.
• Patients trust that coverage is consistent and fair.
• Payers trust that providers are coding and billing with integrity.

In that world, disputes are the exception, not the norm. Administrative costs shrink, affordability improves, and healthcare dollars flow where they belong — into patient care.

Stewardship, not savings alone, is what will move U.S. healthcare closer to affordability and fairness.

Payment integrity will always involve numbers — claims paid, errors reduced, dollars saved. But if we want to build a genuinely sustainable healthcare system, we need to look beyond the spreadsheets.

At Nedl Labs, we believe the real KPI for payment integrity is trust. Because without trust, every dollar saved is a relationship lost. And in healthcare, trust is worth more than money.