Summary
This case study outlines a prepay itemized bill review process implemented by EXL Health for a large health plan in the Midwest, aimed at preventing overpayments on inpatient claims. The client faced challenges due to vague language in their unbundling policy, which led to inconsistencies in reimbursement methodology and provider appeals. To address these issues, EXL Health proposed a two-phased prepay auditing program. The first phase involved identifying applicable claims and reviewing itemized bills against the unbundling policy. EXL's team of registered nurses and quality control experts conducted thorough reviews, resulting in significant savings. The second phase utilized EXLMINE™, a digital audit workflow solution, to enhance the auditing process with tools like optical character recognition and natural language processing. This approach allowed for faster audits and data-driven recommendations, ultimately leading to improved compliance and operational efficiency for the client.
