Case Study: a large national health plan reduces payment errors with EXL Health’s Pre-Pay Audits solution

Large National Health Plan achieves 45-50% hit rate with EXL pre-pay audits

A large national health plan needed a robust pre-pay program that required clinical and analytical expertise to minimize provider abrasion and meet prompt pay regulations. Their challenges included a lack of internal resources for pre-pay processes, slow turnaround times for medical record requests, and concerns over false positives. They engaged EXL and its Pre-Pay Audits solution to address these issues.

EXL implemented its solution using advanced analytics and clinical payment expertise. Their approach leveraged proprietary models for risk scoring, conducted anomaly detection, and used machine learning algorithms to detect complex patterns. This strategy successfully reduced unnecessary medical record requests. The results for the client, driven by EXL, included a 45-50% hit rate and over $7.5 million in cost avoidance identified in 2020.