Payment Accuracy solutions

Unlock value, increase efficiency, and improve performance across the payment cycle with one partner

Claim Editing

Clinical Validation

Billing Accuracy

Contract Compliance

Payment Responsibility

Clinical Chart Validation

Fraud, Waste and Abuse (FWA) Solutions

Break down silos to achieve payment accuracy goals

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.

 

Get more value faster from a proven leader

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

 >$5.4B

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:

  • Identify and close as many improper payment areas as possible
  • Uncover opportunities to find previously unidentified value with insights across all intervention points
  • Reduce your administrative burden across the claim payment cycle
Faster path to value

 60-120

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:

  • Deploy more solutions earlier in the payment process
  • Execute in real-time with leading technologies
  • Implement both claim editing and clinical validation faster with integration
Greater breadth and depth of clinical analytics

 1,000s

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:

  • Widen your layer of defense to cover more payment lifecycle vulnerabilities
  • Deepen the level of analytics and clinical expertise you apply for each area of vulnerability
  • Operate confidently with extensive research on coding compliance, policy, clinical guidelines, and FWA schemes

* 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.

Shape your Payment Accuracy strategy

Unlock value, increase efficiency, and improve performance across the payment cycle

Cotiviti’s Payment Accuracy suite can identify previously unrealized medical and administrative cost savings for healthcare payers by providing solutions for every critical dimension along the claim payment lifecycle—from early payment policy management and clinical claim review to post-pay chart review and fraud pattern investigation. 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.

 Chart_PaymentAccuracyStrategy4

 

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payment_accuracy_solution_billing_accuracyBilling Accuracy

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.

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Billing Accuracy by the numbers

  • Professional claims estimated savings of 1–2%*
  • Outpatient claims estimated savings of 0.5–1.5%*
  • 15+ years of knowledge and content accumulation
  • $1.7B in 2017 total net savings
  • 10+ medical directors
  • 100+ certified coding designations on the team
  • 35+ MDs on our expert panel
payment_accuracy_solution_claim_editingClaim Editing

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.

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Claim Editing by the numbers

  • Potential 1–3%** or more savings on annual medical spend incremental to primary editing systems
  • 300+ rule categories that contain many millions of edit possibilities, combined with a proprietary clinical validation edit library
  • <1 second per claim real-time processing speed
  • Implement in as little as 60–120 days
payment_accuracy_solution_clinical_validationClinical Validation

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.

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Clinical Validation by the numbers

  •  Save another 0.5–1%** off annual professional and outpatient spend incremental to a primary editor
  • 15+ years perfecting the process
  • 200+ nurse code reviewers
  • Implement in as little as 90–120 days
payment_accuracy_solution_contract_complianceContract Compliance 

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.

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Contract Compliance and Payment Responsibility by the numbers

  • Thousands of algorithms to identify payment inaccuracies, resulting in over $3B savings for clients in 2017–2018
  • Estimated savings of 0.50–0.75%** on all claim types
  • >80% of overpaid findings are collected and realized as cost savings
  • 98% provider acceptance rate with contract data versus 79% without
  • 20+ years of experience identifying and collecting COB overpayments
  • Trusted partnership with 5 of the top 6 plans, including the largest national carriers
payment_accuracy_solution_payment_responsibilityPayment Responsibility

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.

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payment_accuracy_solution_clinical_chart_validationClinical Chart Validation

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.

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Clinical Chart Validation by the numbers

  • Savings ranging from 1–2%*** of DRG spend
  • 825+ clinical and coding concepts, rules, and policies
  • Clinical staff with an average of 20 years’ clinical experience per person
payment_accuracy_solution_fraud_waste_abuse_solutionsFraud, Waste, and Abuse Solutions

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.

  • Interceptor identifies potential patterns of fraudulent or abusive claim submissions much earlier in the process than pay-and-chase activities. Identified patterns are analyzed and referred to clients well within prompt-pay requirements, avoiding costly fines and penalties.
  • Sentinel is our post-payment system for automated detection of potential fraud cases, billing misunderstandings and mistakes, and non-adherence to medical policies. Top payers rely upon Sentinel to evaluate, compare, rank, and score providers and members. The resulting “Index of Suspicion” ensures that special investigative units (SIUs) receive high-impact leads for cases.
  • Informant is an advanced data analysis tool that supports user-controlled exploration of healthcare data to discover irregularities and isolate questionable billing and payment patterns.
  • Commander is our case tracking “command center” tool that helps build, track, and learn from FWA caseloads.
  • SIU Services include a wide range of program integrity services, from augmenting in-house staff with investigative support to providing a complete and comprehensive outsourced SIU.

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FWA Solutions by the numbers

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

* 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.

Don’t just take our word for it


Here are a few client examples:
Claim Editing and Clinical Validation

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: 

  • $165 million in additional savings (3.4% of paid claims) as the secondary editor
  • $134 million in additional savings (0.7% of paid claims) as the tertiary editor
Billing Accuracy

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: 

  • $7.1 million in annual savings on outpatient claim spend (3.23%)
  • $54 million in annual savings on professional claim spend (4.07%)
Contract Compliance and Payment Responsibility

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.

Clinical Chart Validation
Medical chart reviews are costly and time-consuming. Much of the data is unstructured, such as handwritten physician’s notes. Reviews require the validation of hundreds or even thousands of pages of information. And more challenges arise from a focus on volume over value. Our solution helps clients focus only on charts with the highest potential findings while minimizing clients’ and their providers’ administrative time and cost impact. Our current change rate averages 25–35%—with some clients experiencing much higher rates—and chart changes are sustained 98% of the time.
FWA Solutions
Our clients see ROI of 5:1-15:1, depending on the number of solutions they deploy. With the use of Sentinel and Informant, one client found a pattern of abusive billing from one provider in the area of Definitive Drug Testing. The health plan was able to confidently send a recovery letter to the provider requiring reimbursement for improperly paid claims totaling $1.3 million.

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