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.
Contact us to learn how EXL Health helped other clients transform the way healthcare is delivered, managed and paid.