Payment Accuracy solutions

Payment Policy Management

Identify millions of dollars in prospective payment savings

Payment Policy Management helps you tailor, test, and execute best-practice clinical and payment policies, ensuring compliance to avert incorrect payments.

• Professional and institutional claims estimated savings of 1–3%*
• $2.8B in annual client net savings
• Low rates of provider appeals and inquiries

Learn more about Payment Policy Management

^*Estimates are based upon paid claim spend associated with volume for each claim type.

Coding Validation

Reduce costs from clinically complex claims

Coding Validation adds a last line of defense against inappropriate claims before they are paid—for example, when editing systems pay claim lines with modifiers that override edits.

• Save another 0.50%† off annual professional and outpatient spend incremental to a primary editor
• 200+ nurse code reviewers
• 500M+ prepay claims analyzed annually

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† Conservative savings with Cotiviti as incremental “final filter” to any existing code editing efforts and solutions that a client currently has in place.

Dental Claim Accuracy

Reduce the cost of inappropriate dental claims

Applying advanced clinical and coding algorithms to nationally sourced edits, Dental Claim Accuracy enables dental plans to identify and clinically validate suspect claims before they are paid.

• Save 2% or more on annual dental spend after primary editing
• Reduce cost and efforts of postpay audit and recovery
• Achieve total dental cost containment in a single solution

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Claim Pattern Review

Identify and validate potentially fraudulent or abusive claims prior to payment

Cotiviti's Claim Pattern Review solution is an automated, pre-payment, early-warning detection system used to flag providers who warrant immediate investigation.

• Projected average prepay savings of ~0.30% off annual professional claim spend*
• 50+ credentialed investigative and clinical support staff

Learn more about Claim Pattern Review

^* Based off of actual client savings. Individual results will vary.

Clinical Chart Validation

Find more value with less administrative burden and provider abrasion

Industry-leading prospective and retrospective analytics—guided by physicians, nurses, and coders and based on clinical insights—verify that claims are supported by clinical documentation to determine reimbursement thresholds, clinical appropriateness, and proper claim payment.

• Save up to >3.5% on annual DRG, short stay, and readmissions spend
• 37% average change rate of retrospectively reviewed charts
• 96% sustainability rates for best-in-class accuracy

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Coordination of Benefits (COB) Validation

Achieve greater accuracy from COB determinations

COB Validation delivers prospective and retrospective claim review for other party liability and deep and broad coordination of benefits (COB) determinations that look at more members and paid claim types, spanning across all medical products.

• >$745M saved by clients in 2022
• >30% additional medical cost savings beyond internal teams and vendors
• Trusted partner to five of the top six health plans

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Data Mining

Save medical costs by finding undetected billing compliance issues

Cotiviti's Data Mining solution enables health plans to identify and recover billing and payment errors through advanced analytics and expert validation.

• >$1.7B overpayment findings in 2022
• Save up to >0.50% on medical spend
• Minimal 2–3% overturn rate when findings are appealed

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Contract Compliance

Recover an average 16 percent more with contract data alone

Contract Compliance enhances accuracy in the application of liability, coverage, and payment terms for contracted agreements. Our healthcare claims accuracy experts use proprietary analytics and data-mining tools to find overpayments that might otherwise go undetected.

• More than $520 million of validated findings recovered in 2019, not including duplicates or pharmacy
• 16% average increase in recoveries due to contract data alone
• 98% provider acceptance rate with contract data versus 79% without

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Fraud, Waste, and Abuse Management

Detect and deter fraud, waste, and abuse (FWA) for up to 15:1 ROI

Designed by credentialed investigators in collaboration with clinical, claims, and regulatory specialists, Cotiviti's end-to-end FWA Management solutions adapt to emerging fraud schemes and compliance requirements.

• Documented ROI of up to 15:1‡
• 23+ years of experience providing FWA software solutions
• 50+ credentialed investigative and clinical support staff

Learn more about FWA Management

‡ Based on actual client results. Individual organization results may vary.