Claim Pattern Review

Prevent fraud, waste, and abuse in healthcare
before claims are paid; flag providers that
warrant immediate investigation

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Claim Pattern Review is part of Cotiviti's
Payment Accuracy solution suite.

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There are many reasons why fraudulent claims get paid—from insufficient staff and disparate record systems to incomplete data sets and mandated processing efficiencies. But health plans don’t need to wait until these erroneous claims are paid, only realizing issues in hindsight.

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of surveyed organizations agreed that avoiding improper claims before payment was a challenge that requires payment integrity solutions.*

Get ahead of fraud, waste, and abuse (FWA) before claims are paid—with Cotiviti's Claim Pattern Review prepay solution.

Our Claim Pattern Review prepay solution helps maximize return by preventing the payment of claims found to be part of a pattern of waste or abuse. We use numerous data points to identify potential patterns of FWA early in the claim process, impeding suspect claims and flagging those providers that warrant immediate investigation. In doing so, Claim Pattern Review increases staff productivity by proactively identifying potential bad billing behaviors—and helps special investigative units (SIUs) build cases against those committing fraud.

With this solution, our clients see results:


in prospective savings over a three-year period across more than 200 providers


saved from just one diagnostic testing scheme


physicians and 16 alleged accomplices—identified from prepay analytics—indicted on 800+ counts of fraud


Claim Pattern Review benefits and features

Prevent FWA before payment with a solution you can trust. Our Claim Pattern Review solution provides several benefits including:

  • 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. Apply retrospective learnings prospectively. Get possible fraud case referrals earlier to help minimize future losses.
  • Save more, improve compliance. Get a positive ROI by only paying on proven savings with no ongoing software fees, and meet prompt-pay requirements to avoid fines and penalties.
  • 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—Claim Pattern Review is powered by more than 50 specialists, including registered nurses and certified fraud professionals.

*Source: TechValidate. TVID: B98-B02-C9A

Maximize ROI with dedicated professionals

With Claim Pattern Review, health plans see increased staff productivity without extensive training. The solution maximizes resources already in place, seamlessly integrating with the processes of health plans of any size. Claim Pattern Review supports analysts, investigators, and auditors who work with extensive and often unpredictable combinations of data and reports, providing them the ability to switch directions and follow new data-driven indicators to expand findings.

We leverage vast clinical experience in many areas, from anesthesia to vascular surgery, to support FWA investigations. Cotiviti's 50+ specialists support all aspects of health plans' payment integrity programs. These professionals mine data and conduct medical record reviews and on average have more than 20 years of proven market experience in FWA.

  • AHFI (Accredited healthcare fraud investigators)
  • CDC (Certified dental coders)
  • CHCA (Certified healthcare chart auditors)
  • CPC (Certified professional coders)
  • Practicing pharmacists
  • RN (Registered nurses)

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