Case Study on Payment Integrity Program Success

This case study details the collaboration between a large national health plan and EXL Health to enhance the payment integrity business. The health plan faced challenges due to limited resources, including a shortage of certified coders and clinical reviewers, and a fragmented operational structure. EXL Health implemented a strategic model leveraging a global workforce and data-led digital solutions to centralize operations and target claims for revenue growth. The operational matrix model integrated subject matter experts across various specialties, improving the efficiency of claims processing. The collaboration resulted in significant improvements, including a 3x increase in revenue and a 233% increase in staff, enhancing productivity and quality while maintaining a low audit error rate. The partnership has positioned EXL Health as the client's preferred vendor, demonstrating the effectiveness of their innovative approach in achieving scalability and impactful results.