360 Pattern Review

A health plan's special investigations unit (SIU) often must overcome challenges like overwhelmed or insufficient staff, disparate record systems, and incomplete reports or data sets in the fight against fraud, waste, and abuse (FWA). Many plans deploy homegrown solutions or rely on limited identification software, but this often results in having to sift through false-positive leads while wasting valuable time and resources. Compounding these difficulties, implementing many of the FWA solutions currently available in the marketplace would require them to uproot their existing teams and systems.

Discover more in payment integrity

Cotiviti's 360 Pattern Review delivers true FWA prevention and management across the entire claim payment cycle while complementing your existing program and people.

Our solution combines the power of Cotiviti’s prepay Claim Pattern Review and postpay FWA Pattern Review solutions to stop FWA in its tracks:

• Claim Pattern Review analyzes prepay claims and other data points to identify suspicious patterns and prevent inappropriate claims from being paid while still meeting prompt-pay requirements
• FWA Pattern Review delivers high-quality leads vetted by our team of credentialed FWA experts to drive efficient postpay investigations and more recoveries

With Cotiviti, clients benefit from:

360 Pattern Review solution benefits and features

Our end-to-end solution deploys the latest in provider scoring models, including artificial intelligence (AI) and expert-driven rules, and our industry-leading managed service model means you can increase the savings value of your current programs without disruption. Our approach also includes a full range of optional program integrity services, from record retrieval, to augmenting your staff with investigative support, to providing a complete and comprehensive outsourced SIU.

Health plans gain benefits that include:

• Rapid ROI through automated detection. Detect claims tied to aberrant provider patterns in utilization, coding mismatches, and outlier billing activities—all while meeting prompt-pay laws.
• Identify potential fraud earlier with a 360-degree view of provider billing. Apply retrospective learnings prospectively. Get possible fraud case referrals earlier to help minimize future losses.
• Eliminate wasted time spent on false-positive leads. Our expert team vets postpay leads for you so you can focus your efforts on the cases more likely to deliver tangible results.
• Boost staff productivity. Increase SIU staff productivity without displacing current resources or systems. Help identify providers with the highest probability of FWA and streamline investigative processes.
• Gain professional support. Rules, analytics, and SIU analysis are continuously updated by Cotiviti's cross-continuum payment solutions. And it's not just software—360 Pattern Review is powered by more than 70 specialists, including registered nurses and certified fraud professionals.