As health plan claim volumes grow amid cost increases and changing guidelines, the opportunity for inappropriate claims to slip through the cracks and get paid grows, too. Especially when plans use a siloed and disconnected approach to payment integrity.
Cotiviti's Payment Accuracy suite helps you knock down those silos by shortening time-to-results from more than 90 days to less than five with an integrated pre and postpayment program. And with dynamic solutions that can work together to review 100% of all major claim types at the right intervention point, our clients can flexibly manage their MLR and unlock more incremental savings value, with less burden on provider partners and administrative teams. Watch this short video to learn more.
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
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.
More savings opportunities
in medical cost savings delivered in 2021*
Faster path to value
days until identification of savings begins**
Greater breadth and depth of analytics
of payment rules, policies, and concepts spanning prospective and retrospective intervention points
A trusted partner
21 of the top 25
national payers are clients, with nearly 100 unique payer clients total
* 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.
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.Learn more
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 eBook
Improve payment integrity and speed-to-value all along the continuum
Identify millions of dollars in prospective payment savings
Reduce costs from clinically complex claims
Reduce the cost of inappropriate dental claims
Identify and validate potentially fraudulent or abusive claims prior to payment
Save 1 to 2 percent of DRG spend with comprehensive medical record review services
Realize 80 percent of overpaid findings as cost savings
Save medical costs by finding undetected billing compliance issues
Recover an average 16 percent more with contract data alone
Detect and deter fraud, waste, and abuse (FWA) for up to 15:1 ROI
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.Read more