The Client

A top 5 health plan serving more than 8 million members nationwide had a sophisticated, mature, in-house claims cost containment department, but outsourced select claims overpayment identification, prevention & recovery activities.

Client’s Challenges

  • Provider contracting has various special payment rules for high cost drugs/specialty pharmaceuticals
  • The health plan’s claims systems did not appropriately pay various situations
  • Internal claim audit team lacked the expertise necessary to identify, stop or recover overpayments effectively on these J-code claims
  • Existing vendors were not “specialists” in the specialty pharmaceuticals area

EXL’s Solutions

  • Review claims from all key provider types in all key places of service
  • Our program applied specialized data analytics/data mining to flag claims based on coding issues we know to be problematic
  • Some claims are determined to be overpaid without further review. For others, clinical experts review medical records to validate preliminary findings, including onsite audits if appropriate


  • Minimal provider disruption
  • Improved claims processing accuracy on specialty drug claims, following our identification of several systematic errors
  • Client renegotiated several provider contracts based on payment issues we identified

Business Value

  • With EXL’s help, over $500,000 per month in identified overpayments (over $6M per year) were recovered

Analytics Model

  • Payment analytics
  • Data mining
  • Clinical review
  • Pharmacist verification
  • High cost drug expertise

Engagement Model

  • Staff Resourcing
  • Proprietary/IP solution

Written by EXL Health Team

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