Contract Compliance

Confirm adherence to complex payment contractual terms and regulations


The facts

Healthcare claims must be quickly and accurately reimbursed according to differing provider contractual terms, prompt pay laws, and other state regulations. At the same time, payers must keep data safe and in compliance with all regulatory mandates such as HIPAA, HITECH, and SOC.

Cotiviti’s Contract Compliance solution enhances accuracy in the application of liability, coverage, and payment terms for contracted agreements. Our healthcare claim accuracy experts use proprietary analytics and data-mining tools to find overpayments that might otherwise go undetected. We work with our payer clients to configure claim reviews specific to relevant regulation and contracted policy. When we identify an error, we provide clients with full details and supporting documentation, then work closely with them to facilitate recovery—all with minimum disruption to providers and network relationships.


Safeguard contract compliance at every point in the claim payment cycle

Identify overpayments that might otherwise go undetected using advanced analytics

Gain help from contract management experts to improve payment accuracy while minimizing provider disruption

Stay price competitive while improving member satisfaction with the billing process

Keep a close eye on the full payment cycle with our deep data assets

Cotiviti uses precision analytics leveraged within each client’s payment integrity program to deliver innovative overpayment findings, yielding higher savings and improved payment accuracy. We compile a repository of provider contracts, including rate schedules, fee schedules, amendments, and contractual language. We note special agreements and exclusions, effective dates, recovery audit look-back periods, and specialty items such as transplants, transfers, implants, and well-baby provisions. Our contract audit tool models unique provider contracts and validates provider compliance with contract terms and conditions.

Contract Compliance can preemptively identify claim categories that should not be processed or that should be handled differently within the claim cycle. We enable multiple types of interventions preemptively, during claim processing or after claim payment, as well as client-specific interventions at every point in the claim payment cycle.


Apply the knowledge of dedicated experts

To minimize required client resources, Cotiviti focuses on hiring and retaining talented subject matter experts who combine their industry knowledge with an advanced understanding of your operating environment and strategic priorities to provide exceptional results. Our specialty auditors focus on claim payment compliance with contractual rate and reimbursement language. The audit team conducts root-cause analysis on post-pay recovery findings to understand why errors occurred and prevent them from happening again. Closed-loop resolution reviews, system updates, and contractual amendments combine with system load revisions and provider network management to continuously improve payment accuracy and speed.

Our team advises plans on provider impact prior to executing new polices. They work diligently to allow you to remain price competitive for consumers while avoiding the member dissatisfaction caused by billing inaccuracies. Our processes also minimize provider abrasion by deploying precision analytics to ensure each payment request, denial, or change is defensible, and each chart request has a high likelihood of a finding.

Feel confident with proven results

Cotiviti is uniquely capable of identifying value from payment accuracy opportunities at multiple points in the claim cycle. We provide complete claim validation, not just extrapolation of results. We take in all forms of client claims and related data and generate contract compliance-related data through proprietary methods, independent sources, and predictive analytics. Our integrated program across prospective and retrospective payment functions makes us an industry rarity—a one-stop shop for your payment accuracy needs.


Results that speak for themselves

More than $520 million of validated findings recovered annually

16 percent average increase in recoveries due to contract data alone

98 percent provider acceptance rate with contract data versus 79 percent without

Get your fact sheet today