Payment integrity programs are moving beyond a post-payment approach to identify billing and payment anomalies before claims are paid. By shifting payment integrity audit activities earlier in the claims-adjudication process, payers achieve improved efficiencies, greater insights, and higher savings through improper payments prevention, without upsetting the claim adjudication lifecycle.

Leverage digital technologies to deliver speed and accuracy

Through innovative digital transformation, prepayment audits are now a significant and cost-effective component within a payment integrity program. Prepayment solutions allow payers to attain their aggressive payment accuracy goals, and when collaborating with the right partner, minimizes disruption to the claim lifecycle and your provider network.

For over a decade, EXL Health’s prepayment auditing services has combined sophisticated analytics with unmatched clinical expertise to efficiently assist with selection and thoroughly review claims before payment errors are made.

Identify billing and payment anomalies in real-time

Successful prepayment programs require the best digital technologies available. At EXL Health, our cloud-based, real-time rules and analytics engine is the latest and most innovative technology in the industry, running advanced algorithms to identify and score each claim’s risk of payment error based on a weighted assessment to enable accurate and comprehensive results. Leveraging both AI and machine learning, we designed our solution to include both accuracy and speed, minimizing provider abrasion by selecting the right claims to reduce false positive and prevent interruptions to the provider’s revenue cycle.

EXL Health provides a full spectrum of Payment Integrity programs in both pre-pay and post-pay arenas. We partner with our clients to proactively manage cost of care spend, improve quality outcomes, optimize network performance, accelerate revenue recognition, and drive member experience. As a flexible and collaborative partner, we work with our client to implement solutions that best fit their unique business challenges.

Diagnosis-Related Group (DRG) Audits: Based on deep clinical and industry expertise, EXL Health’s DRG Program focuses on a comprehensive review of medical records to validate, and recode if necessary, to prevent and recover overpaid claims. Available in both pre-pay and post-pay modalities, our program has a proven track record, with true positive rates above 30%, and several hundred thousand DRG validations conducted.

Itemized Bill Review (IBR) Audits: EXL Health’s pre-pay Itemized Bill Review auditing services deliver a thorough review to identify faults and billing errors that result in unnecessary costs. Leveraging sound analytics, deep clinical understanding of payment patterns, market trends, provider billing history, advanced predictive models and supported by an experienced team of clinicians, our IBR program is a modular and flexible application that increases the ability to detect and prevent overpayments while allowing control of the entire audit process.

Implant Review: Our Implant Audit Program is designed to address the unique challenges of billing implantable devices, including both provider billing and plan payment errors. Based on advanced data and analytics, EXL utilizes evidence-based industry guidelines to detect billing anomalies in implant usage, and a thorough claims-review process to recoup potential overpayments.

High-cost drug (HCD) Auditing: With a focus on specialty pharmaceuticals, home infusion providers, ambulatory care centers, outpatient clinics and office-based specialists, EXL’s high-cost drug audit program recovers millions of dollars in overpayments for our clients annually. By leveraging industry knowledge, clinical expertise, competitive intelligence, and advanced data analytics, we work as flexible, collaborative partner to meet our clients’ needs to identify potential overpayments and inappropriate billing patterns.

Let’s partner your way to correct the payment lifecycle

With over 20 years of experience in Payment Integrity Services, EXL Health applies our deep domain expertise to partner with our clients to create customized solutions, deploying one or multiple tactics, to best manage their audit lifecycle to reduce provider abrasion and address their unique business challenges.

By selecting the right claims upfront, we reduce false positives and see less payments impacted for providers. Providers also see value as our pre-payment auditing services alleviate administrative and financial burdens of denial management and post-payment audit appeals. EXL Health Payment Integrity Services is proud to have achieved 99.6% procedural accuracy and 98.8% payment accuracy.