Payment integrity leaders agree on the direction: shift left. In a recent Everest Group survey of leaders across 40+ health plans, roughly 70% expect their pre-pay investment to increase in the coming months, by an average of 25%. The urgency is real. The Centers for Medicare and Medicaid Services (CMS) reported approximately $96 billion in improper payments across Medicare, Medicaid, Children’s Health Insurance Program (CHIP), and Advance Premium Tax Credits (APTC) for the Federally-facilitated Exchange (FFE) in FY2025. This comes at a time when national health expenditure growth (5.4% projected through 2034) is outpacing GDP growth (4.1%).
So why is adoption still stalling?
The pre-pay paradox
Most health plans already have the building blocks for efficient pre-pay operations: claims editing platforms, clinical coverage guidelines, coding logic, contract terms, provider data, and analytics that can flag risk patterns. The problem is that these capabilities live in disconnected systems. Claims editing sits apart from clinical guidelines. Contract terms require separate interpretation. Provider history isn't integrated into adjudication. Each capability works well on its own, yet none of them work together.
Pre-pay compounds this problem. Unlike post-pay, there's no time cushion. Decisions must happen while the claim is still moving. CMS data shows what's at stake: 77.17% of Medicaid and 56.07% of CHIP improper payments in FY2025 were tied to insufficient documentation – not fraud, not complex clinical disputes, just the operational failure to assemble evidence fast enough.
Why more point solutions won't fix it
The market has responded predictably: more tools, more vendors, more specialized review towers. Yet Everest Group's research shows payer satisfaction is strongest where work is delivered as contained services. The gap opens when pre-pay must function as one integrated decisioning model, spanning evidence, rules, analytics, and human review, all before payment. Adding another disconnected point solution just adds another silo.
This is the paradox many leaders now recognize. You can buy more intelligence and still fall short, because intelligence scattered across systems can't act as one.
The fix: Systems of execution
This is where agentic systems of execution (SoE) come in.
A system of record stores information. A system of engagement supports interactions. A system of execution acts. It assembles evidence, interprets clinical and contract logic, recommends or triggers next-best actions, and routes exceptions to human reviewers, with documented rationale at every step.
Critically, an SoE sits on top of the systems payers already run. It doesn't require rip-and-replace modernization. That makes it a durable orchestration layer, one that can absorb new tools and models over time without rebuilding the workflow from scratch.
For health plan leaders wary of disruption, this matters. You keep your existing investments. You connect them. And you gain a governed backbone that turns fragmented capabilities into coordinated action.
The bottom line
The pre-pay gap isn't an execution gap more than an intelligence gap.
Health plans already own the building blocks: claims editing, clinical guidelines, coding logic, contract terms, and provider data. What they lack is a way to make those capabilities act together, in real time, before payment. The plans that build a governed SoE backbone, rather than chasing full autonomy or bolting on another point solution, will stop leakage before it happens without sacrificing provider trust or compliance posture.
That's precisely the shift EXL’s approach to payment integrity delivers. Rather than fragmented tools acting in isolation, EXL connects data, operational depth, clinical intelligence, and agentic AI into one unified execution environment. The result isn't another layer on a broken model. It's a durable, continuously improving capability that gets sharper with every claim, appeal, and payment decision. For health plans, the outcomes land where they matter most: up to 50 bps of annual medical loss ratio improvement and 15% to 20% per-member-per-month savings at enterprise scale. Decisions move faster, provider abrasion drops, and a governed execution model compounds every gain over time.
The building blocks are already in place. The opportunity now is to make them execute.
Curious why pre-pay adoption keeps hitting roadblocks? Our latest report breaks down the barriers and shows how agentic systems of execution give health plans a path to scale responsibly. Read the full report.