Case Study: a large national health plan achieves $7.5M+ in cost avoidance with EXL Pre-Pay Audits

Pre-pay clinical payment integrity program drives results

EXL worked with a large national health plan that needed a robust pre-pay clinical payment integrity program. The health plan wanted clinical and analytical expertise to support internal resources, speed up processing to meet prompt pay regulations, and reduce provider abrasion and false positives.

EXL Health’s Pre-Pay Audits solution used proprietary risk scoring, anomaly detection, outlier analysis, machine learning, and provider abrasion analytics to improve claim selection and reduce medical record requests. EXL reported a 45-50% hit rate with the clinical pre-pay program, identified more than $7.5 million in cost avoidance in 2020, and delivered substantial pre-pay findings as a subsequent pass vendor.