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