Challenge
A large regional health insurer was faced with a variety of challenges that often come with rapid expansion. In order to successfully scale their operations, one of their primary goals was to reduce or eliminate payment discrepancies post adjudication, prior to payment. This would help manage the growth of costs associated with administration and internal staffing as their volumes continued to grow.
In addition to concurrent processing, the customer was also looking for a solution that could perform retrospective overpayment identification in order to recoup outstanding receivables and thereby reduce losses. The platform needed to be capable of arriving at expected payments, comparing them to the actual paid amount, and performing daily reconciliations.
Solution
After a careful review of the customer’s legacy process and goals for future improvement, Exela implemented a custom-configured solution, combining our Payment Integrity platform with expert supplementary services.
By interfacing directly with the customer’s adjudication system, Exela was able to provide daily payment discrepancy reports as well as identify retrospective overpayments to be recovered. Through issue tracking, root cause analysis, and enhanced reporting, Exela enabled the customer to remit correct payment amounts and adjust their adjudication system accordingly.
As the engagement progressed, payment discrepancies were able to be identified and corrected before they were issued, preventing overpayments as well as additional costs associated with rework and reprocessing.
Benefits
- $12.5M in retrospective overpayments identified
- <1% payment discrepancies (down from 9%)
- Significant savings achieved by avoiding duplication of efforts and reprocessing
- Operation streamlined, enabling a headcount reduction
- A single technology platform interfaced with the customer’s adjudication system
- Enhanced reporting, issue tracking, and root-cause analysis