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 clients for over a decade.
More savings opportunities
in medical cost savings*
We’ve been able to deliver nearly $6B in medical cost savings for our clients across our portfolio by enabling them to:
Faster path to value
until identification of savings begins
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 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. With us, you can:
* Based on recent, actual client-accepted savings 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. Payment Policy Management averages about 150 days for real-time implementation, depending on client resources.
Improve accuracy and speed-to-value all along the continuum
Why? Because avoiding 100 percent of an inappropriate claim is always better than spending time and resources to recover less than 70 percent after the fact, irritating providers in the process. We help clients work more effectively across their payment accuracy silos by deploying the right approach at the right time, driven by a full-service model and the deepest industry expertise.
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. Our team leads the industry in payment rules development and knowledge, which we share with clients to conduct post-adjudication, pre-pay automated reviews. Savings can add up to millions.
Payment Policy Management by the numbers
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. We apply advanced algorithms to nationally sourced edits that flag suspect claims for our team of nurses and coding experts to review before payment. We make payment recommendations within just a few hours.
Coding Validation by the numbers
Identify and validate potentially fraudulent or abusive claims prior to payment
Cotiviti’s FWA Validation solution is an automated, pre-payment, early-warning detection system used to flag providers who warrant immediate investigation. Using rules that are based on utilization, financial profiles, and documented high impact schemes, FWA Validation provides an “Index of Suspicion” for every provider and their patterns around at-risk dollars.
FWA Validation by the numbers
Save 1 to 2 percent of DRG spend with comprehensive medical record review services
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. We also apply lessons learned serving a broad range of payers, including commercial plans, Medicare Advantage, Medicaid, and the Centers for Medicare & Medicaid Services (CMS). And our deep analysis combines coding, documentation, and clinical chart reviews to reveal higher-value errors that others may miss. Not only could your findings increase with Cotiviti, but our comprehensive prospective and retrospective solution reduces unnecessary provider requests and keeps costs sustainable.
Clinical Chart Validation by the numbers
Realize 80 percent of overpaid findings as cost savings
COB Validation provides deep and broad coordination of benefits (COB) determination that looks at more members and paid 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 recover overpayments.
COB Validation by the numbers
Save medical costs by finding undetected billing compliance issues
Cotiviti’s Payment Data Validation solution enables health plans to identify and recover billing and payment errors through advanced analytics and expert validation. Leveraging proprietary analytics and data mining tools, our healthcare claim accuracy specialists find overpayments that might otherwise go undetected. With a proven recovery management process and team that helps drive superior recovery performance, our solution significantly outperforms most collection programs.
Payment Data Validation by the numbers
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.
Contract Compliance by the numbers
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. 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 Management by the numbers
* Estimates are based upon paid claim spend associated with volume for each claim type.
† Conservative savings with Cotiviti as incremental “final filter” to any existing code editing efforts and solutions that a client currently has in place.
‡ Based on actual client results. Individual organization results may vary.