Human ingenuity in action: Self-service investigation capabilities saves millions
Investigators knew they needed to shorten the turnaround time to get these reports back to the requestor and minimize the resources utilized to create these reports manually.
Challenge
A large U.S. health insurer sought to optimize their team specializing in identifying fraud and abuse. This process required investigators to run trend reports and identify the outliers, manually examine multiple data sources to identify trends, and then hand off the report to the original requestor for review.
This approach was resource-intensive, requiring a high number of employees to create each report, as well as time consuming. It took up to 48 hours for four full-time employees to process 250 of hese reports – a metric the client wanted to improve.
Investigators knew they needed to shorten the turnaround time to get these reports back to the requestor and minimize the resources utilized to create these reports manually.
Designed using a complete understanding of the client’s coverage guidelines and billing rules, it enabled audit staff to perform comprehensive reviews for each claim they received. By providing reviewers with the information needed to clearly communicate the reasons for their findings, future appeals would be minimized as well.
Human ingenuity in action
Collaborating closely with the client, EXL Health and came up with a solution of creating a self-serve capability to address both the areas
Using an interactive visualization tool, a new streamlined view was created. This parameterized view pulls all the required summarizations from claims, including data on members, providers, and dates to evaluate potential issues. The report can be easily shared with other parties assisting with the investigation.
This tool was created with EXL’s “Select Right, Audit Right, Make It Stick” philosophy for payment integrity in mind. By leveraging this tool, investigators were able to view all the required summarizations, trend, and outliers based on claims, member, and provider data. The report can be created as a PDF, and easily shared with other parties assisting with the investigation.
Our philosophy for payment integrity
Select right
We use a complete understanding of our clients’ specific coverage guidelines & billling rules and our analytic tools to make the most effective audit selections.
Audit right
Our audit staff looks beyond a claim’s selection reasons and performs comprehensive reviews for each claim they receive. This approach yields maximum error findings.
Make it stick
We minimize appeals by communicating audit results to providers clearly and include reasons for findings. This increases the likellihood of producing a sign-off
Outcomes
By creating this self-service reporting tool, investigators can generate the reports at any given point of the day. The report has become 100% self-sufficient with zero dependency on manual data exports, transfers and loads.
Additionally, by automating the process, this client was able to immediately realize $250,000 in savings by redeploying four full-time employees previously assigned to higher value tasks.
Most importantly, the client is now able to investigate more providers and identify potential fraud much faster, resulting in an estimated savings of $2 million annually.