Clinical Chart Validation

Find more value with less administrative burden and provider abrasion

The facts

Reviewing clinical charts to validate that key diagnoses and procedures on claims are properly supported is costly and time-consuming. When payers concentrate on reviewing as many charts as possible, they waste time and resources while risking their provider relationships addressing overpayments with a low return on investment. In addition, although coding errors and documentation issues are important to catch, they don’t always add up to high-dollar overpayments.

Cotiviti’s Clinical Chart Validation solution goes beyond coding and documentation review with a comprehensive prospective and retrospective solution that reduces unnecessary provider requests and keeps costs sustainable.

Benefits

Save up to 4 percent or more on annual DRG, short stay, and readmissions spend

Isolate charts with the highest probability of overpayment

Catch higher-value errors that others miss with coding, documentation, and clinical validation

Minimize provider abrasion with direct physician involvement in chart reviews

Catch more overpayments prospectively by reviewing more than just the highest-dollar claims

Maximize the payment integrity value chain

Cotiviti is the only vendor to provide a comprehensive program of prospective and retrospective claim reviews of inpatient DRGs, short stays, and readmissions. Our industry-leading team uses machine learning to help isolate charts with the highest probability of overpayment, while deeper analysis—combining coding, documentation, and clinical chart reviews—reveals higher-value errors that others miss. We drive better results through: 

  • Analytics-driven chart selection: Industry-leading prospective and retrospective analytics yield more value with an improved provider experience. Retrospective results based on a client’s specific claims and provider behaviors inform the appropriate mix of claim volume and providers to analyze prospectively, increasing change rates across both programs. Prospective change rates are an expected 70 percent or higher, with retrospective rates averaging 30 to 35 percent.
  • Technology-enabled chart acquisition: Automation replaces many manual processes for program tracking, monitoring, and letter generation. Charts are retrieved faster and more efficiently.
  • Comprehensive coding and clinical validation: An in-depth review of clinical protocols is the first step to unlocking hidden value and improving payment accuracy. The second is relying on specialists with a deep understanding of proper coding and an average 20 years of clinical experience.
  • Trusted audit support and communications: Full-time medical directors lead reviews and appeals conducted by nursing and coding teams with significant credentials and extensive experience. Our required continuing education keeps the team up to date on the latest rules and regulations.
  • Client support and reporting: Our client service managers become extensions of the client’s team, offering clarity and visibility every step of the way. They coordinate and engage on-staff subject matter experts and ensure clients are well informed of claims status through every step of the chart review process.
  • Continuous improvement: At every level, our review and appeals processes deliver continuous improvement. Data from each review is fed back into the process, insights lead to new concepts for our auditors to test and deploy, and advanced analytic methods improve the selection process.

  

Experienced people with deep industry expertise

Cotiviti’s team has real-world experience and possesses a deep, inherent understanding of evidence-based medical literature and its connection to proper claims coding. Led by a team of full-time physician medical directors, our auditors are registered nurses and credentialed coding experts with an average 20 years of clinical experience.

Our team operates in a culture of continuous learning, and is dedicated to accommodating unique client requirements and delivering reliable results. Before they conduct their first chart review, auditors must complete our rigorous onboarding and training process accredited by AAPC. We further require them to complete monthly education sessions to hone their skills and keep audit sustainability, quality, and consistency high.

Proven results

Cotiviti delivers a real and positive impact on selection rate, change rate, and sustainability rate. Direct physician involvement in reviews and appeals sets Cotiviti apart. Applying best practices, clinical insight, and intelligence from chart review through claim resolution, our medical directors conduct research, direct protocol reviews, and handle provider consultations on your behalf, physician to physician. Going beyond the standard rules of correct coding, our auditors consult with provider medical directors to review why particular claims were changed, fostering engagement while reducing the likelihood of a poor provider experience.

 

Results we have delivered include:

Average savings of 4 percent on DRG, short stay, and readmissions spend

30 to 35 percent average change rate of retrospectively reviewed charts

70 percent or higher change rates expected for prospectively reviewed charts*

80 percent or higher chart receipt rates expected for prospective program*

96 percent sustainability rate of audit findings

600,000+ medical charts reviewed in the last year

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