Multi-State Health Plan Payment Integrity Case Study

This case study details the collaboration between a large commercial health insurance carrier and Vālenz® Health aimed at enhancing the existing payment integrity program. The health plan faced challenges due to a rising trend of high-cost claims and sought specialized capabilities to support its payment integrity team. Vālenz implemented its Full Claim Review Solution, which involved a comprehensive line-item bill review conducted by clinical experts, including DRG coding and clinical validation. In 2023, Valenz reviewed over 3,100 claims amounting to $1.24 billion in allowed charges, resulting in $120 million in additional savings, averaging $40,000 per claim. Following these successful outcomes, the health plan plans to expand its bill review services with Valenz, which typically yields an additional 30% savings over contracted network discounts. The study illustrates the effectiveness of integrating AI and expert clinical review in managing high-dollar claims.