Ambulatory Payment Classification Program Case Study

This case study details the implementation of an ambulatory payment classification (APC) program by EXL Health for a leading health and well-being company. The objective was to streamline the client's APC program, which reviews various outpatient care procedures for appropriate payment. The client faced challenges due to a high volume of claims requiring auditing by multiple payment integrity vendors. EXL Health utilized advanced technologies such as data science, AI, and machine learning to develop a targeted model that minimized overlap with higher pass vendors. Over a 24-month period, the team analyzed approximately 20 million claims monthly, successfully identifying significant overpayments and erroneous claims. The program achieved a 322% increase in overpayment identification during its second year, resulting in substantial recoveries and savings for the client. The partnership with EXL Health positioned them as the client's largest market share holder for the APC program, highlighting the effectiveness of their approach.