So why is adoption stalling?
Most health plans already have the building blocks:
Claims editing platforms
Clinical coverage guidelines
Coding logic
Contract terms
Provider data
Risk analytics
The problem? They live in disconnected systems. Each works well alone. None work together.
Callout quote: Payers hold more intelligence than ever, yet they lack the operational speed pre-pay demands. When capabilities are disconnected and intelligence is scattered across systems, payers and providers can’t solve billing and payment issues before they progress.
Pre-pay has no time cushion
Unlike post-pay, pre-pay decisions must happen while the claim is still moving. There's no time to chase down evidence after the fact.
Key stat:
- 77.17% of Medicaid improper payments trace back to insufficient documentation
- 56.07% of CHIP improper payments — same root cause, same preventable problem
Insight line: The leading cause of improper payments doesn’t stem from fraud or clinical disputes, but the failure to assemble evidence within constricted timeframes. The teams getting it right are working smarter as well as moving faster.
More tools don’t equal better outcomes
The market's response to these issues has been predictable: more vendors, more specialized review towers, more point solutions. But adding another disconnected tool adds another silo without addressing the root cause.
Key insight: The best pre-pay programs don't work in silos; they come from connected capabilities and shared intelligence. When systems work together, operating as an integrated decisioning model, the right action happens faster, with less friction and more confidence.
The fix: Agentic systems of execution
Pre-pay decisions require the full picture, but the answer never lives in just one place. The right solution connects data across every system, coordinates intelligent agents working in parallel, and orchestrates the right action in real time.
System Type: What It Does
System of Record: Stores information including claims, policies, payment rules, audit history
System of Engagement: Supports interactions across workflows
System of Execution: Acts - assembles evidence, interprets logic, triggers next-best actions, routes exceptions
Key points:
- Sits on top of existing systems - no rip-and-replace
- Connects what you already own
- Absorbs new tools and models over time
- Documents rationale at every step
- Governed backbone for coordinated action
The bottom line
Health plans already own the building blocks. What they lack is a way to make them act together, in real time, before payment.
Callout line: The plans that build a governed execution backbone — rather than chasing full autonomy or bolting on another point solution - will stop leakage before it happens.
How EXL goes beyond
EXL connects data, operational depth, clinical intelligence, and agentic AI into one unified execution environment, without replacing existing systems. The result is faster pre-pay decisions, less payment leakage, and a governed model that scales. This creates a durable, continuously improving capability that gets sharper with every claim, appeal, and payment decision.
Outcome stats:
- Up to 50 bps annual medical loss ratio improvement
- 15–20% per-member-per-month savings at enterprise scale
- Faster, more accurate decisions with less provider abrasion
- Governed execution that compounds gains over time
The building blocks are in place. It's time to make them execute.
Read the full Everest Group research report to see how agentic systems of execution give health plans a path to scale pre-pay – responsibly.