A collaborative partnership leads to an ever-evolving payment integrity program


One of the top national healthcare payers had increasingly ambitious goals for its payment integrity efforts but struggled to innovate due to its traditional vendor ecosystem, legacy processes, and capabilities of its large internal team. While the internal team had made incremental changes, the results were not industry leading nor significant enough to meet the client’s aggressive targets. Similarly, the payer’s external partners were largely set in their ways and did not drive innovation. The client’s main priorities to revamp their payment integrity program included:

  • The use of robust analytics to drive savings and insights
  • Accurate forecasting and insightful reporting on auditing efforts
  • Efforts to improve and reduce provider abrasion

What the plan needed was a true partner that could effectively blend and collaborate with its internal team to transform its payment landscape and maintain its market leading position.

Our Approach

EXL Health partnered with the client to understand their needs and program goals and implemented a custom solution to uncover opportunities to improve results. Leveraging advanced analytics and extensive knowledge, the EXL Health team identified areas with a high medical-claims spend but a low number of audits conducted by the client and its other vendors. By reviewing these areas, as well as the client’s various payment methodologies, contracts, and clinical and payment policies, EXL Health’s skilled subject matter experts identified opportunities for improvement, including areas where additional auditing was likely to yield substantial wins.

EXL Health implemented new auditing programs for the client, applying sophisticated artificial intelligence (AI) and machine learning, deep domain expertise and proprietary technologies to optimize performance, minimize touch points and reduce provider abrasion. EXL Health also performed a detailed assessment and review of the payer’s internal processes and systems to identify additional opportunities to improve efficiency and optimize savings.

Human ingenuity

EXL Health’s approach delivered significant improvements to the plan’s payment integrity program, and, more importantly, fostered a consultative relationship that provided substantial and ongoing benefits. The streamlined and revamped program continues to see returns and includes efforts to:

  • Identify sizable opportunities which were not being pursued by the client’s internal teams or external vendors, including thorough reviews of claims from outpatient facilities, professionals, skilled nursing facilities, durable medical equipment providers, and home health agencies.
  • Audit claims that had been reviewed previously by another vendor that had not found errors, identifying a 33% findings rate with additional material overpayments.
  • Improve the process for additional, incremental reviews to close the gap created when the client’s internal team was underperforming with a spike in audit volumes under a pre-pay process.
  • Develop a cutting-edge system to enable the ability to review claims substantially earlier in the payment lifecycle, resulting in better results and faster improvements to the bottom line.
  • Replace outdated and inflexible processes with agile and sophisticated innovation, allowing the client to customize and transform their ecosystem to optimize payment and clinical policies, leverage analytics for provider contract terms and payment methodologies, and mine clinical records via natural language processing and AI.