A national health plan with over 8 million members and longtime client sought to reduce the overpayments resulting from common errors in improper CPT coding.

Selection: EXL/SCIO combined its expertise in healthcare and analytics to develop and train its analytical models to pick FWA patterns and built algorithms to identify potential overpaid claims.

Clinical Review: Highly qualified and certified coders, clinicians and registered nurse auditors (15+ years of experience) perform in-depth reviews and validating whether reimbursement matched the services the patient received.

Results: $7.8M overpayments recovered per year, 98% accuracy rate and 120 day average recovery period. Positive changes in billing behavior by providers.

Contract discrepancies observed across providers for large national health plan. The terms of the contracts - which were originally agreed to on paper -- did not get imported correctly into the plan’s information system for a variety of reasons. Indeed, the inaccuracies were turning up because of improper contract load, incorrect coding and/or tied to incorrect member plan information. Results- 16M in overpayments/year and 98% ROI for the health plan.


Client- State of New Mexico Medicaid program and Care and Wellness client

All state Medicaid patients in SW receive wellness points via a care management outreach program for Diabetes. HbA1c compliance increased 286% with incentive engagement as participants earn more points. Inpatient PMPM and average cost per hospital event decreased 70% as participants in a Diabetes care management program earn more points – $354 PMPM decreased to $106 PMPM. Compliance with interventions and care plan increases as participants earn more points. A study between Program participant and Non participants among Diabetes patients show drop in overall cost, while improving prescription use and preventive office visits by avoiding Inpatient utilizations


Risk Adjustment enabled collaboration – The health plan needed a way to better engage the provider groups they worked with to close documentation gaps that were lowering HCC RAF scores used in Medicare Advantage reimbursement calculations. EXL provided analytics, provider education and health assessment tools to improve continuity of care and enabling payer-provider collaboration resulting in 38% Care Gaps closure and $24M savings for a 65K+ member health plan in Texas

Large NE Medical group affiliated with large academic medical center and ACO: Medical Group serving as the physician foundation for a large health system needed to identify key areas across their risk adjustment and quality programs in which they should focus in order to improve revenue accuracy and quality outcomes. Based on the analytics insights and delivery of provider education on coding and documentation best practices this medical group was able to improve their HCC RAF score by 16%, they also identified 1.6M opportunity from chart reviews and have a YTD program ROI of 9.6x


Large national health plan as part of EXL capabilities to perform utilization management and clinical outsourced services EXL develop a digital platform and embedded robotics to automate key clinical processes including prior authorization and pre-certification.


  • Manual and complex verification, validation as per input from multiple channels
  • Multiple touch points due to scattered data points and information
  • Error prone data evaluations due to manual intensive efforts

EXL Solution

  • Eliminate non-clinical work for USRNs such that they focus on clinical decision making
  • Intelligent logic and rule based aggregation of patient data from multiple sources, automated clinical evaluation, validation and verification for decision support
  • Faster processing by emulating human actions and decisions
  • Automated Clinical real time case summarization
  • Replicable & Scalable Solution for Pre-Determination as well as Retro Claim evaluations with minimal lead time

Written by EXL Health Team

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