Payment Accuracy solutions

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

CMS RAC

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.

 

 

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TechValidate

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

 >$5.7B

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:

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

 60-120 days

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:

  • Deploy more solutions earlier in the payment process
  • Execute in real-time with leading technologies
  • Implement all of our solutions faster with a unified data approach
Greater breadth and depth of 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. With us, you can:

  • Avoid more, pay-and-chase less
  • Identify and close more improper payment areas
  • Reduce administrative burden across the claim payment cycle

* 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.


 TechValidate

Improve accuracy and speed-to-value all along the continuum

Cotiviti is leading the way forward—delivering more prospective payment accuracy solutions that empower health plans to catch inappropriate claims before they’re paid.

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.

 

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payment_accuracy_solution_pament-policy-managementPayment Policy Management

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.

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Payment Policy Management 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 annual client net savings
  • 10+ medical directors
  • 100+ certified coding designations on the team
  • 35+ MDs on our expert panel
payment_accuracy_solution_clinical_validationCoding Validation

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.

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Coding Validation by the numbers

  • Save another 0.25–0.75%† off annual professional and outpatient spend incremental to a primary editor
  • 15+ years perfecting the process
  • 200+ nurse code reviewers
  • 500M+ pre-pay claims analyzed annually
payment_accuracy_solution_fwa_validationFWA Validation

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.

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FWA Validation by the numbers

  • ROI of up to 10:1*
  • 50+ credentialed investigative and clinical support staff
payment_accuracy_solution_clinical_chart_validationClinical Chart Validation

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.

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Clinical Chart Validation by the numbers

  • Savings ranging from 1–2%* of DRG spend and 0.5—1% each of short stay and readmission spend
  • 30–35% average change rate of retrospectively reviewed charts
  • 70% targeted change rate of prospectively reviewed charts
  • 96% sustainability of audit findings
  • Clinical staff with an average of 23 years’ clinical experience per person
payment_accuracy_solution_payment_responsibilityCOB Validation

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.

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COB Validation by the numbers

  • More than $390 million in annual cost savings generated for clients including specialty drugs covered under medical benefits
  • Trusted partner to five of the top six health plans
payment_accuracy_solution_payment_data_validationPayment Data Validation

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.

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Payment Data Validation by the numbers

  • More than $300 million in overpayments identified and recovered in 2019
  • Minimal 2–3% overturn rate when findings are appealed
  • >95% accuracy achieved with our validated findings
payment_accuracy_solution_contract_complianceContract Compliance 

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.

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Contract Compliance by the numbers

  • More than $520 million of validated findings recovered annually, not including duplicates or pharmacy
  • 16% average increase in recoveries due to contract data alone
  • 98% provider acceptance rate with contract data versus 79% without
payment_accuracy_solution_fraud_waste_abuse_solutionsFraud, Waste, and Abuse Management

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.

  • 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 Management 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

* 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.

 

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Here are a few client examples:
Contract Compliance and COB Validation

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.

Coding Validation

All of our clients are applying some level of standard, automated claim editing when we start with them. We find that the more clinically complex, improper claims passing through automated rules amount to many millions of dollars—between 0.25–0.75 percent of their annual spend on professional and outpatient facility claims. Specific client examples include:

  • $128.5 million in savings added to $192 million in savings from Payment Policy Management
  • $249 million in additional savings after primary editing
FWA Management

Our clients see ROI of 5:1-15:1, depending on the number of solutions they deploy. Using 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.

Payment Policy Management

Our clients experience an average incremental, clinically defensible medical cost savings of 1–2 percent for professional claims and 0.5–1.5 percent 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
  • $54 million in annual savings on professional claim spend
Clinical Chart Validation

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.

 

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