Behavioral health now accounts for roughly 10% of total medical spend and oversight hasn't kept pace. One large Medicaid plan faced mounting overpayment risk driven by documentation gaps, inconsistent coding, and high-denial service types. They needed a smarter approach.
From hidden exposure to measurable recovery
The plan partnered with EXL to implement a targeted, human-led payment integrity program pairing advanced analytics with a cross-functional team of nurses, social workers, and billing specialists. Claims that missed policy thresholds were flagged automatically, then reviewed by clinical experts who validated documentation, identified coding errors, and determined correct payment levels.
What started as a single-provider review uncovered systemic billing gaps across the audited population.
The results across 4,474 audited claims:
The plan partnered with EXL to implement a targeted, human-led payment integrity program pairing advanced analytics with a cross-functional team of nurses, social workers, and billing specialists. Claims that missed policy thresholds were flagged automatically, then reviewed by clinical experts who validated documentation, identified coding errors, and determined correct payment levels.
What started as a single-provider review uncovered systemic billing gaps across the audited population.
The results across 4,474 audited claims:
This wasn't reactive cost cleanup. It was proactive payment integrity grounded in clinical judgment, not black-box automation.
The question isn't whether to address behavioral health payment integrity. It's how quickly you can act.