EXL’s cognitive medical review system

Client

Our client is a Medicare Administrative Contractor (MAC), responsible for administering Medicare claims for the Centers for Medicare and Medicaid Services (CMS).

Challenge

  • Powerfully transform Medical Review function and process
  • Realize a strong, competitive advantage through improved business performance
  • Add machine intelligence, to streamline and automate the overall process
  • Make MR smarter through integration of information, experience, and learning
  • Build a platform to inform future decisions and strategies

Background

MACs reduce over- and underpayments to providers by identifying and resolving billing errors. Called Medical Review (MR), the process uses data analysis and benchmark metrics to determine a MAC’s overall effectiveness.

This MAC’s critical business need? Increase MR effectiveness beyond that of their competitors.

Benefits of EXL’s CMRS

  • 90% improvement in MR ROI
  • Provides advanced learning system with flexible and proactive detection to enable a ‘living MR strategy’ Reduces overpayments
  • Reduces manual MR effort
  • Leverages an actionable level of payment denial reasons in structured forms
  • Supports targeted provider education aligned with specific denial reasons

The EXL Solution

  • Leveraging Data Unleashed® features such as ontologies and a triple store to create an agile data federation environment
  • Using predictive analytics to drive effective use of clinical review resources
  • Leveraging a finer granularity of payment denial reasons, in structured form, benefitting provider education and future predictive modeling accuracy
  • Supporting targeted provider education aligned with the specific denial reasons
  • Enhancing provider claim submission knowledge resulting in fewer errors and reduced demand across provider support operations
  • Improving provider satisfaction through more targeted and effective communication
  • Driving medical review agility through ongoing monitoring of effectiveness across the review lifecycle
    • Incorporating the review experience, captured in the structured format, into the overall learning loop for proactive error detection within the claim payment proces
       

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