How to Insource Payment Integrity Audits – Part 2: Finding the Right New Audits

In Part 1 of our series, [Maximizing What You Have], we talked about making the most of your existing audits. If you haven’t checked it out yet, we recommend starting there—it’s the foundation for everything else.

Now, let’s move on to the next step: figuring out which new audits you should bring in and how to prioritize them. With the healthcare world changing so quickly, the key to staying ahead is building an audit strategy that adapts to new challenges and opportunities.

Spotting the Right Audits

When adding new audits, the focus should always be on the highest return on investment (ROI) and what matters most to your organization. Some key areas to consider include:

• Pre-Payment Fraud Detection

• Coordination of Benefits

• Clinical Validation Audits

• Contract Compliance Audits

These areas can quickly drive value while strengthening your overall audit strategy.

The BOT Model: A Smarter Way to Scale

A practical way to bring in new audits is the BOT (Build, Operate, Transfer) model. It gives you the benefit of outside expertise while still setting you up for long-term success.

• Build: Start with a strong payment integrity platform—something that supports multiple audit types, has a centralized document repository, AI-powered analytics, automated workflows, and robust reporting.

• Operate: In the beginning, you can outsource operations or use augmented staff. This helps you launch audits quickly, tap into expert knowledge, and test ROI before fully committing.

• Transfer: Once you’ve validated success, you can start moving operations in-house. That means training your team, building internal expertise, and creating repeatable best practices
  

Setting Priorities

When it comes to sequencing your audits, a few guidelines help:

• Start with pre-payment audits—they prevent costly post-payment recoveries later.

• Prioritize audits that address your organization’s biggest pain points first.

• Keep regulatory and compliance needs front and center.

• Evaluate how each audit type might affect provider relationships.
  

Using Technology to Your Advantage

The right tech can make all the difference. Think:

• RPA (robotic process automation) to handle repetitive tasks

• AI and machine learning for predictive analytics and anomaly detection

• Strong data analytics for ongoing risk assessment and smarter planning

By blending technology with a strategic rollout, health plans can boost efficiency, reduce errors, and drive better financial results

What to Look for in a Platform

For insourcing to work long-term, you’ll need a platform that can do it all:

• Centralized data management

• AI and machine learning analytics

• Automated workflows

• Customizable rules and edits

• Strong reporting and insights

• Easy integration with your existing systems

A platform like this keeps everything streamlined, cuts costs, and makes audits more effective across the board. And it already exists. Introducing Replay

Ready to Take the Next Step?

By combining the right audits, a smart rollout strategy, and the right technology, health plans can take control of their audit programs—and see serious savings.

Curious how Lyric can help with your payment integrity challenges?

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About Lyric

Lyric is the payment integrity Al company trusted by the nation's leading health plans at the beginning of the claims payment workflow. The Lyric platform is built on Al from the ground up and trained on 35 years of clinical expertise with real time integrations across 190 million lives. Lyric reduces wasted healthcare spending and ensures fast, accurate payments that drive transparency between payers and providers. Lyric is recognized as the 2025 Best in KLAS for Pre-payment Accuracy and Integrity.