Multistate Health Plan Case Study on Claim Errors

This case study details the collaboration between a large commercial health insurance carrier and Vālenz Health® to enhance the payment integrity program by identifying errors and overpayments in high-cost claims. The health plan faced challenges due to a rising trend in high-cost claims and sought a partner with specialized capabilities to integrate with its existing team. The solution implemented was the Valenz Clinical Bill Review, which involved a comprehensive line-item review of claims by clinical experts, including diagnosis-related group coding and clinical validation. In 2023, Valenz reviewed over 3,100 claims, leading to significant savings of $120 million, averaging $40,000 savings per claim. The health plan plans to expand its review services with Valenz based on these results, which also indicated that the Clinical Bill Review typically yields an additional 30% savings over contracted network discounts. This case study illustrates the effectiveness of specialized claim review solutions in managing high-cost claims.