Clinical Validation

Reduce annual claim spend by 1 percent or more

The facts

Today’s claim editing systems address black-and-white coding situations, but cannot manage situation-dependent coding rules, such as the use of modifiers to override typical edits. A payer must either risk millions of dollars in improper payments or expend significant resources to develop an army of clinical claim reviewers. 

Cotiviti has a better option: Clinical Validation. This unique market offering adds a last line of defense against costly overpayments and recoveries—for example, when editing systems pay lines with modifiers that override edits. Clinical Validation applies advanced clinical and coding algorithms to nationally sourced edits and flags suspect claims that our team of nurses and coding experts review before final adjudication. We render payment recommendations within a few hours, causing no payment delays for your providers. A complementary offering that easily integrates with our Claim Editing solution, Clinical Validation can also be used on its own.

Benefits

Reduce annual claim spend by 1 percent or more

Increase payment policy compliance and the accuracy of claim payments

Redistribute valuable clinical and IT resources

Pay quickly and accurately with a proven process and team

Cotiviti has spent more than 15 years perfecting our Clinical Validation process for more than 60 payer clients to balance accuracy with speed. Our registered nurse coders have the knowledge and experience to determine a claim’s accuracy using data on the claim and claim history, without cumbersome medical record review. Clinical Validation workflow is performed in “near time” or batch mode, and results are sent within just a few hours after receipt of edited claims. The result: fewer improper claims, and no penalties caused by delays in payment. 

Cotiviti’s expert nurses and coders are certified by AAPC or AHIMA. We employ more than 200 full-time and part-time nurses and coders to quickly scale to any claim volume. Each team member goes through an extensive eight-month onboarding and training process and must maintain certifications in accordance with their respective professional organization’s requirements. Cotiviti nurses are trained in multiple specialties to make more accurate recommendations and to support provider reconsiderations.  

 

Avoid the burden of clinical content and IT maintenance

Because Clinical Validation is a software-as-a-service (SaaS) offering, Cotiviti efficiently handles updates to sourced and proprietary editing and payment guidelines, technology infrastructure (e.g., hardware, software, software updates), and system configurations (e.g., edit configurations, customizations). Our clients have the peace of mind that expert resources are being deployed, but none of the hassle of maintaining that expertise in-house.

 

Minimize the pain of the provider inquiry process

Cotiviti’s payment recommendations are sourced from nationally recognized coding standards to ensure that denials or payment reductions are defensible. In cases where providers inquire about these decisions, our clinical experts review the medical records submitted by providers, make an adjustment recommendation, and provide detailed rationale to support our coding and payment recommendations.

Feel confident with proven results

No matter the line of business or membership size, plans have the potential to save 1 percent or more on their annual medical spend incremental to primary editing systems by detecting improperly coded claims.

Although individual plan results vary, Figure 1 illustrates an example of the distribution of savings from Clinical Validation edits.

 

Example client savings* include:

$1 million in additional savings

(~1 percent of paid claims) in just the first quarter of 2018

$23 million in additional savings

(~0.5 percent of paid claims) in just the first quarter of 2018


FIGURE 1

Mix of Clinical Validation savings by edit type

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*Based on actual client results. Individual results will vary by client.

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