Payer priorities

Aligning with healthcare payers’ key needs

Marketplace realities put tremendous pressure on the organizations that provide health insurance across the United States. It’s a complex environment with many interdependencies. Cotiviti’s approach to payment accuracy helps you address the fundamental issues impacting your business.

Click on a challenge to learn more.

Across the healthcare industry, reductions in unwarranted cost and waste have become critical priorities. Payers play a key role by ensuring that accurate payments are made for the appropriate delivery of care. Each inaccurately paid claim represents waste in our healthcare system, and it’s vitally important to bring accuracy to all payments.

One of the best ways to control medical costs is to ensure accuracy as thoroughly as possible, by verifying that claims are correct, properly coded and documented, and paid in accordance with payer policies, clinical guidelines and provider agreements. The key is to seize opportunities both prospectively (before the payment) and retrospectively (after the payment is made). That can be a very complex undertaking.

Achieving that accuracy across a high volume of claims demands analytic insight and knowledgeable, technologically enhanced engagement. Cotiviti addresses critical payment determinations in multiple areas, from policy optimization and management to clinical chart validation and contract compliance.

The solutions that Cotiviti Healthcare employs to manage unwarranted medical costs are comprehensive and repeatable. They’re driven by industry expertise, data and analytics – knowledge and insights that enable payers to achieve meaningful, ongoing value by gaining a better understanding of the data they already possess.

Cotiviti goes beyond identifying issues and irregularities. We act on what we find and rectify issues – capturing value when inaccuracies are detected, rather than simply reporting.

Going hand-in-hand with medical cost is the cost of contract, policy and payment administration – the time and labor needed to keep policy content up-to-date, evaluate and edit claims, establish liability, review documentation and reconcile overpayments.

Controlling administrative costs is about efficiency and cost-effectiveness both before and after payment. Cotiviti’s holistic approach helps clients achieve accuracy more thoroughly and potentially earlier in the payment continuum. In this way, many unnecessary costs can be avoided in the first place.

Understanding the drivers of cost across the payment continuum is essential to managing administrative costs. There may be inefficient processes, systemic issues with coding, policies that are out of date, difficulties with coordination of benefits, backlogs of claims to approve, or internal filters that allow billing errors to slip by. Often, a payer simply lacks the resources to fully address these issues.

As a specialist in payment accuracy, Cotiviti Healthcare complements our clients’ teams, delivering results more cost-effectively than payers can on their own. Because we are able to combine industry-wide scale and capacity with proven best practices and advantages in research, content, expertise and analytics, our clients are better able to manage administrative costs year after year.

Staying abreast of constantly changing regulations and industry guidelines is vital in order to minimize risk of non-compliance. But there’s more to compliance than regulatory oversight – meeting internal performance mandates and adhering to payment policies and provider agreements is just as important.

Anything that allows an inaccurate payment is a problem. Policies and supporting content must be current and applied correctly – the right information, available at the right time in the right place, whether that’s before or after the payment. The rules, processes and filters that ensure accuracy need to be effective and consistently applied, and the payer needs to know what’s happening across the payment continuum.

Cotiviti Healthcare helps payers achieve operational excellence that fosters better compliance. Drawing on our strength in research and our industry-leading content library, we can take responsibility for keeping policies and supporting content up-to-date. Deep expertise in coding and clinical validation helps to ensure compliance with policies and guidelines, while thorough documentation ensures that all claim decisions are well supported.

For payers, building provider relationships on a foundation of financial accuracy and quality of care is more critical than ever. And, with individuals taking on a greater share of medical costs, the focus on member relations has intensified. Good management of provider relationships benefits payers in many ways, from improved payer-provider collaboration, to lessening the administrative burden related to inaccurate payments, to increased member satisfaction.

The best provider relationships are the ones that run smoothly, with full compliance with policies, clinical guidelines, and contract agreements. Our prospective solutions enhance our clients’ ability to make accurate determinations prior to payment, thus eliminating the impact of post-payment reconciliation on their providers.

Cotiviti Healthcare recognizes how important provider relationships can be. By handling provider interactions with respect and fully documenting retrospective claim decisions, we help ensure alignment between our clients and their providers when payment reconciliation is required. Cotiviti provides our clients the tools and information enable them to educate providers and answer any questions that may arise.

Better accuracy delivers benefits to members too, because there are fewer errors in bills, co-pays and deductibles, and Explanation of Benefit statements. By working to keep the cost of care down, member premiums are kept down. That leads to greater satisfaction for both the provider and the member.


Maximizing accuracy across the payment continuum

Maximizing accuracy at every point in the claims payment process is essential if payers are to compete. That’s central to the Cotiviti approach. We dig deeper, enhancing our clients’ ability to leverage data and attain insight that drives greater overall accuracy, and through it, better results.

Cotiviti views everything that payers do in processing claims as a continuum of decisions and execution points. All activities, before and after payment – medical and payment policy management, adjudication, claim edit, chart review, overpayment recovery and more – are tied to one another.

What happens in one area can significantly impact others, for better or worse. That’s why solutions that target a single business requirement may not deliver the best outcome for the payer or the provider. Our solutions are different: Cotiviti addresses multiple dimensions of payment accuracy, enabling our clients to take into account these critical interdependencies.

Meeting the challenges that payers face requires a deep and wide view to uncover value that’s hard to detect – looking at the data behind each part of the claims and payment process and understanding how it impacts the whole. That’s the benefit of working with Cotiviti Healthcare. As an expert in payment accuracy, we are able to look across the payment continuum, see the business in the context of payers’ overarching priorities, and think innovatively to find the solution that delivers the best overall outcome.