CLIENT NEED

A large national health plan that leverages multiple vendors for payment integrity including DRG audits across multiple lines of business wanted to improve identification and recovery of overpayments while minimizing provider abrasion.

Challenges

  • Substantial internal pressure to identify and recover additional savings across payment programs and lines of business
  • Client was not satisfied with results from existing vendors and saw an opportunity to recover additional dollars more effectively
  • Current vendors’ high DRG false-positive rates caused provider abrasion
  • Limited internal resources to review no findings results from initial pass

EXL Approach

  • Leading advanced analytics, proprietary models and innovative techniques such as machine learning to drive precise claim selection
  • Industry recognized clinical auditing expertise to identify more overpayments
  • Holistic approach with proven hit rates minimize provider abrasion
  • Insights drive an efficient and effective audit process and recommendations to change provider behavior

Over $17M in annual overpayments identified as a lower pass vendor, 35%+ hit rate on previously audited claims, Low Appeal and overturn rates minimize provider abrasion

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