Pre-pay clinical payment integrity program drives results

EXL Health’s Pre-Pay Audits solution addressed the client’s challenges and concerns with its advanced analytics and clinical payment expertise to avoid payment errors.

Challenge

A large national health plan needed a robust pre-pay program, requiring clinical and analytical expertise that minimized the impact on providers while ensuring prompt pay regulations are met.

The challenges faced by the client included:

• The need for clinical and analytics expertise to assist internal resources with pre-pay processes.
• The speed of processes to address prompt pay, medical record request response and turnaround time.
• Concern about provider abrasion and false positives.

Human ingenuity at work

EXL Health’s Pre-Pay Audits solution addressed the client’s challenges and concerns with its advanced analytics and clinical payment expertise to avoid payment errors. EXL Health’s approach was to:

• Leverage proprietary models to score risk and develop member, claim and provider profiles.
• Conduct anomaly detection and outlier analysis.
• Implement machine learning algorithms to detect complex patterns.
• Use provider abrasion analytics to inform selection strategy and reduce MR requests.