Potential fraud and abuse in medical claims represents $80-$160 billion of a $750 billion-dollar wasteful spending problem for the healthcare industry. This creates challenges for health insurers, and claims management alone is not sufficient to identify fraud, waste and abuse or potential subrogation.
There is an opportunity to use care management technology and applied analytics to identify and manage issues of incorrect coding, subrogation, payment errors, non-beneficial services and more. The new provider reimbursement program, set forth by the Affordable Care Act (ACA), increases the effectiveness of pattern recognition analytics which has been used successfully in other industries for years.
By employing these capabilities, health plans can enhance payment integrity outcomes, leading to positive financial results and more collaborative provider-payer relationships.
A large U.S. provider of healthcare, dental, pharmacy, and disability insurance was facing overpaid claims of more than $500 million annually. The client needed a trusted partner to help it identify and validate these claims.
EXL began the engagement by staffing analysts who could find claims with higher propensity to be overpaid. EXL mined millions of claims based on several search parameters, including procedure codes, type of provider and member eligibility. Claims were profiled to understand distribution by procedure codes, billed amount and other important attributes to identify overpayment opportunities.
2 to 5% of all claims from contracted providers are overpaid, which happens because adjudication systems cannot keep up with the updates in various contracts and policies. The client needed a trusted partner to help identify the source and trends associated with overpaid claims.
EXL’s 25 member team worked on a contingency fee model for all commercial and Medicare claims. EXL’s team developed a process to quickly identify the overpayments, validate their findings and set about recovering the overpaid fees.
The Role of Data Federation in Revenue Optimization
“Just as states federate to form a country, data residing within independent data stores can form what appears to be a virtual database to the end user, without ever copying or transferring the data. The relational databases that are the foundation of healthcare can continue to be used and now be can leveraged by bringing in unstructured data sets, such as consumer data or wellness data by county, to improve the customer experience as well as financial and operational performance.”
“Care management programs that solely focus on utilization, case and disease management will need to be reengineered to address broader population health management, value-based payments, provider driven care management, revenue optimization, quality metrics, payment integrity and expense control.”
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