Enabling a pharmacy benefit manager to increase dollar returns 48.6% YOY
A large pharmacy benefit management organization came to EXL Health several years ago to provide a solution to a major issue they were experiencing. EXL Health solved the issue within three months, subsequently going on to generate massive incremental performance improvements for this client with total net recoveries increasing from $35M in 2021 to $52M in 2022.
Challenge
Before coming to EXL Health, this organization’s workflow was centered on a telephone-based prepay review program. As a pharmacy benefit management (PBM) organization, the client reviews pharmaceutical claims for all kinds of areas, including commercial and government.
Using telephone auditors with access to the claim line information, the PBM was having pharmacies reverse claims that appeared to be wrong within a few hours of being submitted. The PBM’s client told them they would not give the PBM credit for an audit recovery when the recovery was done that quickly, as they wanted the pharmacies to have at least two days to reverse the claim on their own.
Human Ingenuity
The PBM’s workflow was set up to make immediate phone calls as their only means of reviewing insurance claims prior to payment. They asked EXL Health to develop a solution that could meet the two-day delay mandate from their large client.
EXL Health proposed an immediate migration to a three-business-day digital solution that requested the prescription for single claims selected for review. EXL Health would conduct the audit review of the prescriptions and send the results to the PBM.
Today, EXL Health sends 1,200 prescription review requests per day. It is a simple process and is exempt from the many state pharmacy audit laws across the USA.
Results
This client was in danger of losing revenue from a particular insurance client contract with their process before coming to EXL Health. By switching to a three-businessday digital solution with EXL Health, the client was not only able to maintain this contract but generate additional sizable recoveries.
Key performance metrics
Total net recoveries for the client increased from $35M to $52M from 2021 to 2022, equating to a 48.6% year-on-year increase.
Total number of individual claims with a monetary recovery increased from 33,680 to 43,119 from 2021 to 2022, equating to a 28% year-on-year increase.
Total hit rate, meaning the percentage of claims that resulted in a monetary recovery, increased from 16.5% to 21.7% from 2021 to 2022, equating to a 31.5% year-on-year increase. EXL Health positioned the client to achieve this performance improvement with 2.55% fewer investigated claim, going from 204,100 to 198,900 year-on-year.
Added benefit: EXL Health also enabled this client to navigate the interstate regulatory landscape across the United States in a frictionless manner and ensure compliance without disrupting the claims review process. This organization’s relationship with their own client has gone from strength to strength in the intervening period since engaging EXL Health’s services.