Payers - including health plans and PBMs - are overpaying providers and pharmacies for treatment of their members by significant amounts.

Whether caused by provider fraud, waste, and abuse (FWA), billing error, or their own payment errors, the result of these overpayments force payers to either raise premiums or reduce benefits. It is, therefore, critical to implement cutting-edge, thoughtfully curated solutions to target the root causes at play.

Specific challenges that limit payment accuracy include:

  • Inherent complexity combined with system/workflow limitations that fail to accurately manage payment and processing requirements
  • Inability to precisely target billing and adjudication errors due to disconnected, disparate data and non-data assets
  • Provider pushback and reluctance to participate in the audit and recovery processes
  • Limited visibility into the performance/ROI of payers’ current efforts
  • Scarce internal resources and expertise to perform thorough reviews
  • Government regulations (e.g. prompt payment timelines)
  • Explosive growth in telehealth and remote care, creating a need for new and innovative approaches to payment integrity

 

EXL HEALTH PAYMENT INTEGRITY SERVICES

Our payment integrity solutions are based on a 360 degree view that integrates the claim, the provider, the payer, and the member for deeper insights.

We help payers refine their selection of high-risk providers while preventing and correcting improper claims payments more efficiently.

We help provider organizations proactively manage risk, improve quality outcomes, optimize network performance, accelerate revenue recognition, and drive member experience.

Based on your needs and preference, we can deliver an end-to-end solution via a fully outsourced managed service model or a hosted environment with an on-premise analytics platform designed for your specific needs.

Digital Transformation

We at EXL Health leverage our multi-payer dataset and aggressively apply digital solutions, such as Artificial Intelligence (AI), natural language processing (NLP) and robotics processing automation (RPA), to maximize performance and financial-related results. Other benefits include:

  • Speed to savings
  • Deeper insights lead to more savings
  • Nimble and extensible solutions
  • Transparent and accessible information
  • Impactful data visualization

"We are very pleased with our partnership with EXL. Their extensive analytics add substantial value in accuracy and produce valuable insights, and their robust clinical auditing processes enable accurate identification of overpayments and improved provider experience. They are a pleasure to work with, and we value each new opportunity to have them help us."

 

 

Why Partner with EXL Health?

  • Our engagements are founded on listening to and understanding your needs. We then rapidly deliver flexible and configurable solutions using a proven framework to address them.
  • We facilitate clear and consistent communications throughout our partnership, including an ongoing feedback loop, to adjust to your changing needs quickly and thoughtfully.
  • We quickly act on industry and regulatory changes — whether via new analytics to detect inappropriate COVID-19 behavior, solutions to guide provider behavior in new/problematic areas like telehealth, or incorporating the transition by CMS of payment methods for home health and skilled nursing facilities.
  • We continually identify new ways to capture savings: data mining, analyzing data, trends and outliers; finding emerging patterns of risk and applying or developing unique solutions.
  • Our expertise uniquely encompasses both non-clinical and clinical domains, with a highly skilled workforce enabling over 20 subclinical programs.
  • We effectively deploy our technology and analytic capabilities across payment life-cycle needs; pre- and post-pay domains and emerging pre-submission applications.
  • You can augment or fully outsource your technology, analytics and staffing needs to EXL Health.