Clinical Chart Validation

Find more value from clinical review and clinical validation—with less administrative burden and provider abrasion

CMS RAC

Discover more in payment integrity


Coding and documentation review only scratches the surface of clinical chart validation. Although coding errors and documentation issues are important to catch, they don’t always add up to high-cost overpayments. And when payers concentrate on reviewing as many charts as possible, they waste time and resources, risking provider relationships by addressing overpayments with low returns on investment.

93%
of surveyed payer organizations are likely to recommend Cotiviti.*

 

Cotiviti’s Clinical Chart Validation solution goes beyond coding and documentation review. Our comprehensive solution reduces unnecessary provider requests and keeps costs sustainable—before and after adjudication.

Our Clinical Chart Validation solution goes beyond the usual coding review to provide a holistic, clinical review that thoroughly analyzes charts to provide better savings. And this solution provides capabilities for both the prospective and retrospective clinical review and validation of claims, delivering results no matter where payers are in the process.

With this solution, our clients benefit from:

96%

sustainability rates for best-in-class accuracy

50%

or greater change rate for prospectively reviewed charts

4%

average savings on DRG, short stay, and readmissions spend

Clinical Chart Validation solution benefits and features

Our industry-leading team uses machine learning to help isolate charts with the highest probability of overpayment of inpatient DRGs, short stays, and readmissions. And deeper analysis combines coding, documentation, and clinical chart reviews to reveal high-value errors that others miss. We drive improved results through:

  • A comprehensive structure. Cotiviti is the only vendor to provide a comprehensive program of prospective and retrospective claim reviews. Our prospective change rates yield an expected 50% or higher, with retrospective rates averaging 30 to 35%.
  • Analytics-driven chart selection. We pride ourselves on industry-leading prospective and retrospective analytics that yield more value with an improved provider experience.
  • Technology-enabled chart acquisition. With our Clinical Chart Validation solution, charts are retrieved faster and more efficiently. Automation replaces many manual processes for program tracking, monitoring, and letter generation.
  • Comprehensive coding and clinical validation. Our specialists conduct an in-depth review of clinical protocols to unlock hidden value and improve payment accuracy. And with an average 20 years of clinical experience each, our clients get results.
  • Trusted audit support and communications. We rely on full-time medical directors to lead reviews and appeals conducted by experienced, credentialed nursing and coding teams. And our required continuing education keeps everyone up to date on the latest rules and regulations.
  • Client support and reporting. Our client service managers are extensions of our client’s team, coordinating and engaging subject matter experts and ensuring 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.

*Source: TechValidate. TVID: C55-FBC-364

Maximize ROI with dedicated professionals

The Clinical Chart Validation solution provides capabilities for both the prospective and retrospective clinical review and validation of inpatient Diagnostic Related Group (DRG), Short Stay (SS), and readmission claims. It utilizes an integrated process that assures appropriate DRG-assignment and payment of inpatient hospital claims by reviewing the patient medical record in accordance with the payer’s claim payment data, while working to maintain and promote positive provider relations. The solution provides these services for Commercial, Medicare, and Medicaid lines of business. 


Discover more in payment integrity

Ready to learn more? Talk to one of our sales representatives—fill out the form below to schedule a call.