Challenge

A large national health plan needed a robust pre-pay program, requiring clinical and analytical expertise that minimized the impact on providers while ensuring prompt pay regulations are met.

The challenges faced by the client included:

 

  • The need for clinical and analytics expertise to assist internal resources with pre-pay processes.
  • The speed of processes to address prompt pay, medical record request response and turnaround time.
  • Concern about provider abrasion and false positives.

Human Ingenuity at Work

EXL Health’s Pre-Pay Audits solution addressed the client’s challenges and concerns with its advanced analytics and clinical payment expertise to avoid payment errors. EXL Health’s approach was to:

  • Leverage proprietary models to score risk and develop member, claim and provider profiles.
  • Conduct anomaly detection and outlier analysis.
  • Implement machine learning algorithms to detect complex patterns.
  • Use provider abrasion analytics to inform selection strategy and reduce MR requests.

Outcomes

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