Payment integrity analytics solution delivers $3M in recoveries annually

Challenge

A leading health and well-being company wanted to streamline their ambulatory payment classification (APC) program. APC is a methodology that reviews procedures, services, drugs and devices within outpatient care settings for appropriate payment.

The client’s millions of members created a substantial number of claims to be audited by multiple payment integrity (PI) vendors. The auditing process is based on the client’s established pass order, a ranked system that allows multiple vendors to select claims with potential impactful findings.

The client came to EXL Health based on their proven track record and positive, collaborative experience partnering together on other programs, and, although EXL Health was not engaged with the client for an outpatient program at the time, the client extended the opportunity for EXL Health to implement an APC program as the client’s lowest pass order.

Human Ingenuity

When developing the model for this client, the EXL Health team took a strategic and highly creative approach. Instead of casting a wide net typical of lower pass vendors, EXL Health built a laser focused, targeted model to avoid overlapping selections that had already been identified by higher pass vendors.

Leveraging state-of-the-art technologies like data science, AI, machine learning, analytics, and natural language processing (NLP) customized for detecting waste, fraud and abuse, EXL Health developed new concepts, rules and principles to identify untapped opportunity areas that would fall within scope per the pass order. EXL Health’s approach was a success, identifying sizeable new overpayments and erroneous claims.

The team continuously analyzed approximately 20M claim monthly pipeline for potential savings for 24 months. EXL Health increased the selection volumes and selection approvals from the client to help deliver significant savings to the client.

Outcomes

Through their partnership with EXL Health, the client attained substantial recoveries, all of which delivered incremental savings that would not have been recovered without the addition of EXL Health as last pass vendor. EXL Health achieved the highest findings rate, holding the largest savings-identified market share, in comparison to the client’s other PI vendors. Till date, EXL Health has continued as the client’s largest market share holder for their APC program.