A large regional Blues plan engaged EXL to apply its analytics and identify areas where overpayments could be prevented.
- Despite its robust processes, at times, the complexity of various payment issues caused systemic errors in payment
- Resources capable of bringing together industry expertise with robust analytics were difficult to find
- Varied payment policies, provider contracts, regulations and procedures meant ongoing efforts to identify systemic issues were required
- Applied complex analytics to flag unusual payment patterns and other potential issues
- Subject matter experts (claims configuration and adjudication, provider contract interpretation, etc.) reviewed issues and determined which could be prevented
- Worked closely with the client, providing feedback regarding issues in the client’s current system of claims payment
- In first 6 months, analysis of client’s overpayment discovery file revealed at least 4 issues causing systemic overpayments
- Combined total opportunity exceeded $12 million
- Client has process in place to assure senior leadership that it is proactively pursuing prevention
- Cost effective global delivery model means work is performed at approximately 50% of cost that client would otherwise incur
Identified issue related to change in payment methodology for a drug used with radiology. The plan had not updated their fee schedule, and it resulted in $2 million in overpayments.
Written by EXL Health Team