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


  • 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 Health Team

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