Postpay Compliance Solutions

Health Insurance Business Intelligence System (HIBIS^®)

HIBIS^® is our signature post payment solution that detects fraud, waste, and abuse for Australian health funds at the forefront of compliance and payment integrity operations. HIBIS^® drives the accurate identification and recovery of inappropriate claims by detecting billing anomalies and supporting the workflow required to recover incorrect payments.

The solution can:

• Process claims through a high-performance rules engine
• Author, test, and deploy rules in real-time without the need for programming
• Support analyst workflow while capturing actions and results
• Deliver flexible and comprehensive management reporting
• Capture diverse types of inappropriate claiming behaviour generating significant savings for customers

HIBIS^® possesses an ever-growing suite of 400+ rules that are adapted as we proactively respond to legislative change, newly detected anomalous behaviours,client requests, and in-house research into new compliance issues.

Prepay Compliance Solutions

Cotiviti's Prepay Compliance Solution (PCS) is a near real-time adjudication system that audits a claim prior to payment. As the last line of defence, PCS integrates with existing claims processing engine, provider communications and workflow management platforms, to create a bespoke compliance system.

Adding Prepay Compliance to Cotiviti's Postpay Compliance Solution can help increase the realised value by an estimated 60% while reducing recovery lag time by more than 90%, freeing resources and reducing costs.

The key components of Prepay Compliance include:

Differentiators

• Significantly less human intervention needed to realise savings
• An ever-growing suite of rules driving additional value and adapting to a changing environment
• No duplication of work between assessors in your claims processing system and HIBIS

Content

• Cotiviti's suite of rules from HIBIS made available to PCS
• All rule customisations from HIBIS transfer to PCS
• Rules maintained and new rules added by Cotiviti

Integration

• A highly efficient workflow built on tight integration with your claims, processing, provider comms, and workflow management vendors
• The ability to choose your level of daily involvement in the prepay compliance process
• The option for oversight of the entire process

Ancillary Compliance Solutions

Gamma is our Ancillary Compliance Solution, an intelligent, bespoke platform for identifying, investigating, and monitoring inappropriate ancillary claiming patterns. Gamma uses a proprietary risk-scoring approach to identify providers, members, or practices with billing behaviour out of step with their peers.

Gamma has been designed in collaboration with health funds to provide solutions that solve analytical and operational issues in ancillary leakage, by using a flexible, analytical, and configurable framework to assess provider claiming trends across a range of behavioural indicators.

Gamma overlays its advanced analytical approaches that:

• Generate significant savings through recovery and behaviour change
• Use algorithms built on extensive experience and data intelligence to capture different inappropriate behaviours such as non-provision or misrepresentation of services, or the delivery of medically unnecessary procedures
• Create communications across a range of channels to intervene with providers, members, or practices of interest
• Analyse ancillary claims from all payment channels such as HICAPS, online, and others

Gamma's combination of advanced analytics, data visualisation techniques, and workflow tools ensure operational efforts focus on cases that return.

The Surveillance Module allows users to transparently track and measure savings inside Gamma. Cotiviti's modelling on previous work suggests Gamma can save funds 2% of their overall ancillary benefits.

Contract Negotiation Solutions

Our Contract Negotiation Module, NeMo, is a platform that supports hospital and payer contract negotiations. NeMo provides negotiation teams with rapid, rich, and granular insights into hospital pricing and quality, combined with workflow support to ensure a streamlined, data-driven negotiation process. Using the insights provided by NeMo, negotiations can move away from price alone towards consideration of provider quality that drives better healthcare outcomes for patients.

The key benefits for negotiators using the tool are:

• Health intelligence on relative provider value, based on historical claims data
• Clear visualisation of peer group comparison on price and quality
• Supporting evidence to compare peer hospitals on quality and pricing over time

With support from the wide variety of cost and pricing methods in the marketplace, NeMo's payment model and forecast calculations may apply to current, future, and "what-if" pricing scenarios with ease. NeMo enables real-time modelling so users can model changes in the lead-up to negotiation and during live discussions.

Up-to-date claims data from providers is imported when provided, which allows users to witness the immediate impact on contract spending due to changes in provider utilisation. NeMo is an upgrade in reliability, accuracy, and speed for teams that currently manage contract negotiations via email and spreadsheets.