Challenge

A leading US-based health plan needed support for their payment integrity professional program, a process that identifies and addresses the overbilling and overpayment of claims generated for work performed by physicians. Professional claims cover certain procedures including labs and tests in various primary care, surgical, and specialty areas. They therefore require highly targeted analytic solutions and domain expertise.

Additionally, the claims generated by the plan’s tens of millions of members required a substantial number of audits. However, the plan’s first-pass vendor was unable to keep pace, resulting in a substantial claims backlog.

Human Ingenuity

• The plan chose EXL Health as an effective, long-term partner bringing expertise and analytics across the claims auditing process, including for professional services. Despite various challenges, EXL quickly launched a program, focusing first on surgical claims with a structured plan to expand to other areas as the program matured and gained experience with the client’s nuances.
• Relying heavily on human ingenuity and its extensive global resources, EXL Health deployed targeting algorithms and proprietary analytics to identify claims with high risk of billing and payment errors based on reviews of clinical information. EXL Health further enhanced the work via experts that added additional concepts and fine-tuned queries over time, delivering high-value results within the larger claims universe.
• As part of building analytic models, the team also accessed the plan’s systems, policies and contracts to ensure work aligned with the client’s specific terms and conditions.
• There was also a concern about overlapping work with the existing vendor. EXL Health established a process that enabled visibility into which vendor was working on specific claims to mitigate overlaps in effort.

Outcomes

Since its launch, EXL has continued to expand the program and maintain a high findings rate and increase recoveries as the process matured.

$17M
in recoveries during the first full year of the program

Over $60M
in overpayment identification during the first full year of the program

60%
average finding rate

$1,745
average dollar overpayment per audited claim

Due to these successful outcomes, the health plan has agreed to expand the program by incorporating prepayment auditing services to identify and address billing and payment anomalies throughout the claims lifecycle.