Clinical Chart Validation
Fraud, Waste, and Abuse (FWA) Solutions
Payers know that their goals must cover the entire payment cycle and be consistent across health plan functions to achieve the desired impact, which means moving beyond a siloed, department-by-department approach. Claims must align with provider contracts, medical policies, industry guidelines, and government regulations all along the way. Payers must constantly balance the challenges of preventing and addressing overpayments quickly while minimizing disruption to providers.
All of this takes knowledge, insight, and thoroughness. That’s what Cotiviti has to offer.
Payment integrity leadership requires experience, scalability, innovation, and proven value. Cotiviti has spent 20+ years honing our solutions specifically to drive exceptional value for our clients all along the claim payment life cycle.
Unwavering dedication to our clients’ success has earned us nearly 100 unique payer clients—from small third-party administrators to 21 of the top 25 national payers, many of which have been Cotiviti partners for over a decade.
More savings opportunities
in medical cost savings*
We’ve been able to deliver more than $5B in medical cost savings opportunities* for our clients across our portfolio. We help you:
Faster path to value
days until identification of savings begin
Our clients’ time to value from our solutions is typically faster than with others, sometimes implementing within as little as 60 days**. We help you:
Greater breadth and depth of clinical analytics
of rules, policies, and concepts
We’ve developed thousands of rules, policies, and payment concepts that all help drive down improper claim costs from prospective through retrospective intervention points. We help you:
* Based on opportunities presented to clients across our portfolio. Individual organization results will vary based on client acceptance of identified opportunities and policies.
** Some Cotiviti post-pay solutions are able to start identifying savings 8-12 weeks from receipt of a valid data file. Claim Editing averages about 120 days for real-time implementation, depending on client resources.
Unlock value, increase efficiency, and improve performance across the payment cycle
Identify millions of dollars in pre- and post-payment savings
Billing Accuracy helps you tailor, test, and execute best-practice clinical and payment policies, ensuring compliance to avert or recover incorrect payments. Our team leads the industry in payment rules development and knowledge, which we share with clients to conduct post-adjudication, pre-pay, and post-pay reviews. Savings can add up to millions.
Billing Accuracy by the numbers
Avoid another 1 to 3 percent in improper claim payment costs
Claim Editing is a software-as-a-service (SaaS) editing technology that can be deployed in the primary position or following another editor to ensure the accuracy of claim payments, increase adjudication speed, and reduce payer technical and clinical resource needs—all while causing no disruption to current adjudication workflow and no delay in payment to providers.
Claim Editing by the numbers
Reduce costs from clinically complex claims up to another 1 percent
Clinical Validation is a unique market offering that adds a line of defense after any editing system against costly overpayments and recoveries caused when systems pay claim lines with modifiers that override edits. Clinical Validation applies advanced clinical and coding algorithms to nationally sourced edits and flags suspect claims that our team of nurses and coding experts review before final adjudication. We render payment recommendations within just a few hours, causing no payment delays.
Clinical Validation by the numbers
Identify 40 to 60 percent more findings with expert audit and recovery
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.
Contract Compliance by the numbers
Realize 80 percent of overpaid findings as cost savings
Payment Responsibility provides deep and broad coordination of benefits (COB) determination that looks at more members and claim types, spanning across all medical products. We provide thorough review and analysis of contracts, eligibility files, third-party benefits agreements, and other data sources to determine payment responsibility and COB.
Payment Responsibility by the numbers
Save 1 to 2 percent of DRG spend with efficient medical record review services
Industry-leading 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. We also apply lessons learned serving a broad range of payers, including commercial plans, Medicare Advantage, Medicaid, and CMS, to our deeper analysis that combines coding, documentation, and clinical chart reviews, revealing higher-value errors that others may miss. Not only could your findings increase with Cotiviti, but because we pull fewer charts and deliver better results, your providers have an improved experience.
Clinical Chart Validation by the numbers
Detect and deter FWA for up to 15:1 ROI
Designed along with clinicians, claims and regulatory experts, administrators, and data analysts, FWA Solutions quickly adapt to emerging fraud schemes and compliance requirements. Data analysis, decisions, and insights from one module can help modify rules and algorithms for other modules, creating an even stronger anti-fraud solution.
FWA Solutions by the numbers
* Conservative savings with Cotiviti as incremental “final filter” to any existing code editing efforts and solutions that a client currently has in place.
** Estimates are based upon paid claims spend associated with volume for each claim type.
*** Based on actual client results. Individual organization results may vary.
All of our clients are applying some level of standard, automated claim editing when we start with them. They soon find, however, that the more clinically complex, improper claims passing through their auto-adjudication rules amount to many millions of dollars—0.5–3% of their annual spend on professional and outpatient facility claims. Examples include:
Our clients experience an average incremental, clinically defensible medical cost savings of 1–2% for professional claims and 0.5–1.5% for outpatient claims, depending on paid claims spend associated with volume for each claim type. Two examples of significant client savings include:
Our clients benefit from our hands-on validation and cross-check of claims against differing provider contracts as well as review and analysis of contracts, eligibility files, and third-party benefits agreements to avoid inappropriate payments and determine payment responsibility and coordination of benefits.
For example, claims submitted for an expensive cancer drug set off red flags. Usually used to treat lung cancer, the drug had been prescribed for a patient who had breast cancer. Cotiviti’s clinical analysis uncovered numerous additional inconsistencies between treatment and use of this medication code. Just one number differentiates the code used and the intended code, leading to a clerical error that caused $80,257 in overpayments. The payer recovered the full amount.