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.
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.
hit rate with clinical pre-pay program
in cost avoidance identified in 2020
Substantial pre-pay findings as a subsequent pass vendor