We are proud to announce Eliza® Member Engagement is now part of Cotiviti!
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Unlock new value with integrated prospective and
retrospective payment integrity solutions
EXECUTE HEALTHCARE CLAIMS EDITING MORE ACCURATELY—WITH LESS PROVIDER ABRASION
A Northeast health plan discovered a rising trend in Evaluation and Management (E&M) over-coding, but was challenged to find a cost-efficient method to combat this high-volume, low-dollar problem. The plan implemented Cotiviti’s new E&M policy, beginning with Level 5 coding outliers, then expanded the program to Level 4 outliers as provider appeals remained low. At the end of the year, the client had saved more than $8 million through Cotiviti’s E&M policy while impacting less than 5 percent of its provider network.
Learn more After several years of realizing strong savings from Cotiviti’s Payment Policy Management solution, a large regional health plan turned to Cotiviti to address other suspected improper payments—specifically, abuse of modifiers 25 and 59. The plan implemented Coding Validation to identify inappropriate claims too complex to be auto-adjudicated and validate them within just a few hours—without the need to request medical records. Ultimately, the plan saved more than $2 per member per month by avoiding these inappropriate claims.
Learn more Our clients experience average retrospective chart change rates of up to 35 percent, or more for specific claim types. For several clients ranging from mid-size to national, our clinical chart reviewers found providers were diagnosing patients with aspiration pneumonia without providing sufficient clinical evidence such as x-rays or CT scans, resulting in a change to a lower-weighted DRG. Our review delivered an average >$4,000 savings per change and resulted in a change rate of 42 percent.
Learn more 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. 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, leading to a clerical error that caused >$80,000 in overpayments. The payer recovered the full amount.
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Although healthcare payments have undergone major transformations over the past decade, one thing remains constant—the need for claims payment integrity is paramount for payers. Learn how to develop a solid foundation for holistic payment success across your prepay, postpay, coordination of benefits, FWA, and other critical programs.
Read the eBookImprove payment integrity and speed-to-value all along the continuum
Payment Policy ManagementIdentify millions of dollars in prospective payment savings
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Coding ValidationReduce costs from clinically complex claims
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Dental Claim AccuracyReduce the cost of inappropriate dental claims
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Claim Pattern ReviewIdentify and validate potentially fraudulent or abusive claims prior to payment
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Clinical Chart ValidationSave 1 to 2 percent of DRG spend with comprehensive medical record review services
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Coordination of Benefits (COB) ValidationRealize 80 percent of overpaid findings as cost savings
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Data MiningSave medical costs by finding undetected billing compliance issues
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Contract Compliance Recover an average 16 percent more with contract data alone
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Fraud, Waste, and Abuse ManagementDetect and deter fraud, waste, and abuse (FWA) for up to 15:1 ROI
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Claim Pattern Review integrates with Cotiviti's post-pay FWA solutions to apply retrospective knowledge and behaviors to prospective edits. Cotiviti identified a diagnostic testing scheme for one client that resulted in several physicians being terminated from its network, their exclusion from state Medicaid and workers' compensation programs, and indictments. The providers involved were immediately placed on pre-payment review to reduce exposure to further overpayments, resulting in more than $10.5 million in prospective FWA savings.
Read more Recovering overpayments from providers can be a contentious process, fraught with potential for abrasion and even litigation. Health plans must perform advanced statistical analysis and extensive medical record review in order to achieve the level of documentation needed to confidently request reimbursement with any likelihood of success. Faced with such a challenge, Health Partners Plans of Pennsylvania worked with Cotiviti to successfully recover more than $1 million in overpayments related to upcoding from a provider group.
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