Payment Integrity Services

Our Payment Integrity Service supports funds by managing their end-to-end prevention and recovery process of inappropriate hospital, medical, and ancillary claims. Our team of experts identify and investigate savings opportunities, freeing valuable resources for health funds and allowing them to redirect their focus elsewhere.

The key components of our Payment Integrity Service include:

• Preventing payment where billing is incorrect
• Post payment debt recovery: for benefits paid incorrectly
• Ability to measure your future savings via changing provider behaviour

In addition to prevention and recovery of benefits paid, further outcomes include:

• Low provider abrasion: Our experts focus on reviewing claims with the highest accuracy.
• Customisation and flexibility: Our solutions are tailored to each customers to suit best market practices and accommodate complex operating environments.
• Reduced FWA: The service plays a vital part in identifying and reducing fraud, waste, and abuse (FWA).
• Low IT and administrative burden: Our expert team ensures our customers do not need to invest in further resourcing or costly updates.
• Unparalleled support: Cotiviti provides dedicated support, including provider communication tools and FWA reporting.

Hospital Audits

On-site hospital audits are a crucial pillar in health funds' Payment Integrity initiatives and are employed to detect and prevent FWA within the healthcare system. These audits focus on examining medical records for selected admissions, ensuring the appropriateness of billing practices.

Auditors physically visit hospitals during this process to inspect patient records and related documentation. Audits are to safeguard financial integrity, prevent unnecessary expenses, and maintain affordable premiums for the members while also upholding high standards of care.

Our Payment Integrity team manages the end-to-end hospital audit process, including:

• Claim selection
• Onsite audit
• Follow-up communications with providers and reimbursements
• Production of clear reports with details of the providers audited, outcomes, their status, and related reimbursements.

Recommendation Service

Cotiviti's Recommendation Service ensures that your team's capacity will no longer limit your savings.

Our team will delve into your fund's HIBIS or Gamma systems, ensuring you only receive reliable claims and providers to review. As a result of this, you will see a significant reduction in false positives and your fund will experience enhanced accuracy of more than 80%, making your payment integrity efforts more efficient.

Our Recommendation service is for funds that:

• Prefer active involvement in the Payment Integrity Process.
• Wish to independently utilise our Postpay/Prepay/Ancillary Compliance Solutions while seeking referrals for claims and providers with the utmost accuracy.

Consulting Practice

Our Consulting Practice service supports customers by addressing crucial areas such as policy, strategy, funding, and compliance integrity. Our team collaborates with various organisations across both public and private sectors.

Our services cover the entire healthcare value chain, including:

Analytics and Reporting

• Healthcare cost trends analysis
• Negotiation support services
• Data-driven reporting of clinical performance
• Advisory services focused on software implementation and integration
• Analysis of claims leakage in general treatment claims, industry benchmarking reports, and analysis of quality of care

Our Consulting Practice compliments our solutions by providing independent insights to accelerate results.