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


  • 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

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