The Client
A health plan serving 2.7 million Medicaid members in 12 states nationwide, required assistance identifying overpayments across all areas.
Client’s Challenges
- Utilized a legacy claims payment platform that was prone to claims payment issues
- Needed a partner to assist in identifying overpayments and correcting future payments
- Faced challenges with multiple state/market payment policies and procedures, as well as internal resource issues
EXL’s Solutions
- Developed tailored algorithms and performed data mining on paid medical claims to identify billing and payment errors
- Conducted additional clinical audits (hospital bill audits, high cost drug audits, durable medical equipment audits) for the client across providers, using our experienced clinical staff
- Worked closely with the client, providing feedback regarding issues in the client’s current system of claims payment
Results
- Identified significant payment errors due to client’s claims payment system
- Provided the client with a clinical presence across various states to perform cost-effective clinical audits
- EXL has used this learning to develop a prepay contract compliance program
Business Value
- EXL identified $1.5M in overpaid dollars for the client over 3 years, and ultimately helped the client fix systemic issues in their claims system, reducing overpayments from $950k in 2010, to $110k in 2012
Analytics Model
- Data analytics
- General overpayments identification and in high cost drugs, hospital bills, DME
Engagement Model
- Staff resourcing
- Standardized output
Written by EXL Health Team