Global operational model triples revenue for national payment integrity program

Challenge

A large national health plan was facing challenges growing their payment integrity business. The organization’s resources were limited, both in the number of employees with payment integrity domain knowledge, including certified coders and clinical reviewers, and the ability to implement innovative concepts to deliver improved results at rapid pace. Despite deep technology expertise, the key operational teams' structure was loosely bound, spread across geographies, and worked in silos. The client came to EXL Health with specific goals in mind:

  • Implement data and digital tools to drive a cohesive, centralized operational structure while targeting the right claims for revenue growth
  • Achieve scalability and fulfill demands of their skilled payment integrity auditors and healthcare experts

Human Ingenuity

Leveraging data-led digitally enabled solutions and a highly trained global workforce, EXL Health implemented a strategic, scalable model that produced significant savings and impactful results.

First, EXL adopted an operational matrix model offshore, integrating subject matter experts with deep domain knowledge across diverse specialties, including data, analytics, clinical concepts, technology and product. The global team collaborated across specialties to go beyond reviewing traditional low-volume, high-dollar claims to find more savings within a broader set of claim types, an approach that would not be economically viable leveraging only US domestic resources, and focused on efforts to accelerate the findings rate, improved true-positive selections and reduced the rate of overturn. The team also established an independent quality function, which strengthened quality layers, overturn rates and profitability in all major audit programs.

Secondly, guided by the EXL team’s collaborative expertise, EXL implemented data-led, digitally enabled solutions that enabled the ability to absorb more claims, identify more data patterns, build new concepts and drive analytics-focused selections. These solutions also supported an easier and faster pace of innovation, such as shift-left initiatives, throughout all programs. To ensure optimal results on the digital transformation process, the EXL team applied a proprietary modeling principle, named the Digi-E framework, which is the guiding roadmap to understand our clients, their end-to-end process, and the impact our digital solutions deliver to the business. This approach ensured that all transformation initiatives helped improve savings yield, reduce gaps, augment productivity, and enhance the provider experience.

As the client grew, EXL Health harnessed the strength of our global workforce to provide scalability for their programs. With significant investments in best of class recruiting and extensive training programs, such as the EXL Academy, EXL was able to easily ramp up resource needs, pulling from our extensive network of certified coders, experienced auditors, USRNs, and other healthcare specialists.

Outcomes

Throughout our three-year partnership, EXL Health has delivered scale and results at a rapid pace. Currently, the client names EXL Health as their first preferred vendor.

Productivity

  • 133% increase in completed audits
  • 15% increase in auditor productivity due to NLP-assisted audits
  • 15% increase on aggregate hit rate; 28% increase on program-specific hit rate
  • 3% to 9% average dispute overturn rate, compared against industry standard of 12% to 15%

Revenue

  • 3x increase in revenue through scalability of operations

Talent

  • 233% increase in staff, ramped up from a team of 300 to 1000+

Quality

  • < 3% audit error rate (AEIR)
  • > 98% vender quality scores

1st pass vendor position achieved