PAYMENT INTEGRITY SYSTEMSM

EXL’s Payment Integrity SystemSM is an enterprise, cloud-based solution that reduces claim overpayments by identifying fraud, waste and abuse.

Powered by our proprietary analytics and rules engine, Payment Integrity SystemSM combines predictive modeling, advanced data visualizations and clinical expertise into a cutting-edge SaaS product.

  • Recovery ROI ranges from 5:1 to 22:1 for payers with fraud and abuse solutions, according to the NHCAA
  • Fully automated overpayment detection with prioritization support
  • Processes more than one billion records a day
  • Claim decisions in as little as 30 seconds
  • $50 million in claims recovered and $20 million in leakage prevented in three years for a single client

Payment-Integrity-ai

PRODUCT HIGHLIGHTS

Process more claims. Reduce handling costs. Increase recoveries, and prevent overpayments.

Overview

  • Integrates clinical alerts, analytics and case management tools into a single solution
  • Centralized activities: refer and learn from identified overpayments
  • No data scientists needed; out-of- the-box analytics are immediately available
  • Browser-based, modular and flexible
  • Robust data management that combines claims intake and mapping with all formats of member and provider data

Workflow and configuration

  • Enhances efficiency with queuing, workflow and case management
  • Dynamic rule building and modeling “sandbox”
  • Fingertip data mining: Drill-down, pre-defined analysis in a single click

A powerful combination of analytics

  • Predictive modeling
  • Regression analysis
  • Benford’s Law and Kolmogorov-Smirnov techniques
  • Cost, financial and outlier models
  • Targeted queries and scoring

Insights and reporting

  • Insights through suite of reports and intuitive dashboards
  • Program performance leadership scorecards
  • Day-to-day managerial reports

Start solving a $40 Billion problem. $2 trillion in claims are paid annually; 2% are estimated to be overpayments.

Companies preventing even 5% achieve significant savings.

We offer quick and effective ways to examine millions of claim records based on complex and changing rules.

THE EXL ADVANTAGE

Strong backbone of analytical techniques

  • Deterministic and probabilistic predictions
  • Clinically-based profiling
  • Aggregates clinical, policy, external and geospatial data
  • Data fusion of external data sets
  • Rules-based decisions for industry standard analysis

Big Data infrastructure to store and process millions of claims

  • No SQL database needed
  • State-of-the-art AngularJS bootstrap frontend
  • Performance to process thousands of claims per second
  • Enhanced UX
  • Multi-tenancy for seamless, multi-user experience

Multiple deployment options

  • Cloud services: On-demand scalable architecture hosted on AWS
  • The EXL Data Warehouse, a secure private cloud
  • On premise deployment with technology integration support

Deep healthcare and analytics expertise

  • 30+ healthcare payer clients
  • 2,100 analytics professionals
  • 50 million members on EXL care management platforms

READY TO LOOK DEEPER?
CONTACT OUR HEALTHCARE LEADERSHIP TEAM.

GET IN TOUCH WITH US

Address
280 Park Avenue, 38th Floor
New York, NY 10017

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