How Longitudinal Data Mining And Analytics Can Optimize Overpayment Recovery

posted by EXL Health

on February 8, 2021

The Overpayment Problem

The complexity of the health care delivery and payment system means health plans frequently overpay for care, in some cases losing millions of dollars that would be far better spent on members who need it. That translates into higher costs for insurers, employers and consumers, who must absorb those wasted dollars. For some Americans, these higher costs could put health insurance and the care it covers out of reach.

The industry has made progress in some areas. For example, the rate of improper payments under Medicare Advantage dropped from 14.1% in 2010 to 9.5% in 2015, according to CMS data.1 However, data problems, contracting issues, opportunistic bad actors and other challenges mean overpayments continue today. Generally, health care providers that are overpaid must return those funds within 60 days, but in most cases it falls to health plans to make providers aware of the issue.

This paper represents the views of the author, not America’s Health Insurance Plans (AHIP). The publication, distribution or posting of this paper by AHIP does not constitute a guaranty of any product or service by AHIP.

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