Payment integrity
Redefining payment integrity: Elevate accuracy, efficiency, and savings with AI
Health plans face rising costs, complex billing, shifting regulations, and friction with providers. Without intelligent tools and AI-driven insights, payment waste, denials, and administrative burden rise, impacting both the bottom line and relationships. EXL combines powerful data analytics, advanced AI, and deep domain expertise to break down and modernize legacy silos and deliver smarter payment accuracy. Our innovative solutions detect errors in real-time, transform raw data into actionable insights, and streamline workflows, resulting in reduced administrative efforts, sustainable financial performance, and stronger payer-provider relationships.
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Common challenges
- Outdated reliance on post-payment audits and reactive recovery misses the opportunity to stop improper payments before they happen, limiting overall savings potential
- Disconnected data and siloed systems block visibility into high-impact opportunities, making it harder to focus on claims that drive the greatest financial results
- Labor-intensive reviews and static rules struggle to keep pace with rising claim volumes and complexity
- Poorly targeted audits cause increased workloads for providers and internal teams alike, resulting in costly disputes and unnecessary friction
The EXL advantage
Why partner with us for payment integrity transformation? Efficiently scale your payment integrity operations through a modular, adaptable approach, leading to more control, transparency, accelerated savings and smarter decision-making.
White-box capability for more control
AI-driven accuracy and speed
Proactive cost avoidance
Unified data intelligence
Reimagining payment integrity for an AI and data-driven future
As healthcare shifts toward a data-driven, patient-centered future, payment integrity programs must evolve to keep pace with this transformation. Explore the key trends and strategies that health plan leaders are adopting to address current payment integrity challenges and future-proof their programs.
Solutions
Transform your payment workflows
Prevent payment leakage
<p>Proactively identify and address billing, coding, contract, and eligibility issues before claims are paid. By integrating AI into claims workflows to instantly flag, prioritize, and route high-risk claims, our prepay editing, clinical review, policy enforcement, fee schedule validation, and prospective COB capabilities help reduce avoidable costs and enable quicker and more effective interventions.</p>
Validate clinical and coding accuracy
<p>By combining specialized audit expertise with advanced AI applied to both structured and unstructured clinical data, our specialized auditing review programs evaluate medical records, identify coding discrepancies, ensure policy alignment, and evaluate complex inpatient, outpatient, professional, pharmacy, behavioral health, home health, and ancillary claims.</p>
Recover improper payments
<p>Focus your recovery efforts where they matter most. We help health plans maximize recoveries while uncovering systemic payment issues that drive long-term value through advanced analytics, coordination of benefits validation, and third-party liability and subrogation services.</p>
Strengthen provider engagement
<p>Foster productive provider relationships through targeted education, appeals management, performance analytics, behavior monitoring, and fraud support. Our data-driven approach reduces provider abrasion, promotes billing accuracy, and drives sustainable improvement in payment integrity outcomes.</p>
Awards and recognition
Spotlight on achievements in excellence
Discover how our AI-driven solutions can transform your payment workflows, enhance accuracy across every transaction, and deliver measurable improvements in cost savings and compliance. Connect with us to explore how a trusted partnership can modernize your operations and unlock sustained financial performance.
What we do
EXL helps payers improve reimbursement by providing insights to control costs, reduce expenditures, and optimize revenue.
Proven outcomes: human ingenuity at work
One of our long-standing payer clients was looking to streamline their payment integrity program, specifically their diagnosis-related group (DRG) auditing solutions. As their most trusted and first-pass post-pay vendor for DRG coding and clinical auditing services, they approached EXL when looking to reduce vendors to decrease administrative and operational workloads within vendor management. Leveraging human ingenuity, technology, and analytics-enabled solutions, EXL’s payment integrity solution was able to impact payment accuracies, cost management, and quality outcomes – all key to value-based performance success.
By partnering with our client to better understand their needs and implement custom solutions, EXL Health was able to create significant value to the organization, yielding an improved savings rate of 120% within 2021 and 2022.
- 56% overall DRG savings for client in 2021
- Expected continued growth in 2022
- Improved resource efficiency due to streamlining from a singular vendor
Testimonials
Our success is our clients’ success
Frequently asked questions
EXL takes a modular, data-led approach that gives payers the flexibility to access software, analytics, clinical expertise, and operational support in any combination. Rather than replacing your existing processes, we integrate with your current infrastructure and expand capabilities over time, delivering impact from day one.
Yes. EXL payment integrity is specifically designed to move payers upstream - from reactive recovery to proactive intervention. Leveraging predictive modeling, machine learning, and real-time anomaly detection, our proactive approach identifies issues early in the claim lifecycle, prevents future inaccuracies, and improves operational efficiency.
EXL applies AI-powered precision to rapidly detect and resolve payment inaccuracies, uncover hidden risks, and minimize improper payments across diverse datasets. By driving better selection, higher yield, and faster savings identification, we help payers recover lost revenue, reduce waste, and deliver more predictable results, without the cost and friction of post-pay recovery.
EXL takes a strategic, provider-centric approach that reduces audit fatigue and rework for all stakeholders. By focusing only on claims that warrant review, accelerating evaluations, and offering clear, policy-referenced feedback, we help correct errors at the source. The result is faster reimbursements, fewer disputes, and greater trust between payers and providers.
