The Client
A top PBM had a manual, inefficient process of reviewing claims prior to payment. Their process lacked scalability and resources to establish a robust program. The client also had inconsistent edits across it's clients and lines of businesses that allowed for payment of inappropriate claims.
Client’s Challenges
- Client has limited IT resources to build a scalable program
- Client was conducting these reviews on an inconsistent, “adhoc” basis with minimal results
- Client needed knowledgeable auditors to review pharmacy claims
EXL’s Solutions
- Deployed infrastructure and data expertise to process 1+ million claims daily
- Developed, tested and deployed daily algorithms
- Completed all reporting and auditing responsibilities
- Daily faxes and phone calls to pharmacies to confirm reversals and resubmissions
Results
- Provide an average of $600,000 per month in cost avoidance
- Top discrepancies revealed:
- Incorrect Days Supply
- Invalid directions
- Billed quantity different than prescribed
- Commonly Reviewed:
- Maximum daily dose
- Package Size
- Injectables
- Insulin Vials/Pens
Featured Services
- Data expertise and Scalability
- Prescription Analytics
- Efficient Audit Software/Workflow Management
- Auditor Expertise
- Compliance Review
- Cost Avoidance
Engagement Model
- Automated Data
- Staff resourcing
- Standardized output
- Proprietary/IP Solution
Written by EXL Healthcare Team