Case Study: Top 5 Health Plan Provider achieves $6M+ annual recovery of specialty drug overpayments with SCIO Health Analytics

Top 5 Health Plan Provider - Customer Case Study

Top 5 Health Plan Provider, a top-five national health plan serving more than 8 million members, faced complex specialty pharmaceutical payment rules, claims system mispayments, and an internal audit team without the specialized expertise to identify, stop, or recover overpayments on J-code/high-cost drug claims. They engaged SCIO Health Analytics for high cost drug auditing and overpayment identification, prevention, and recovery.

SCIO Health Analytics applied specialized payment analytics and data-mining across provider types and places of service, flagging problematic coding and using clinical reviews, pharmacist verification, and onsite audits where needed. The engagement delivered minimal provider disruption, improved claims processing accuracy, enabled renegotiation of several provider contracts, and recovered more than $500,000 per month (over $6M per year) in identified overpayments.