Payment Data Validation

Identify and recover billing and payment errors through advanced analytics and specialist validation

The facts

Healthcare claims must align with myriad best-practice payment policies and nationally accepted coding standards to ensure appropriate payment. While health plans strive to pay claims correctly the first time, this complexity creates challenges for their payment integrity programs and inevitably leads to overpayments. When incorrect payments to providers occur, health plans need definitive and decisive answers backed by strong analytics and pinpoint research to aid in recovery—without impacting their critical provider relationships.

Cotiviti’s Payment Data Validation solution eliminates guesswork by leveraging analytics and data mining tools to find and recover high-value overpayments. Our specialists perform deep analyses on findings to understand why an overpayment occurred and how it can be prevented in the future. And throughout the process, Cotiviti maintains strong lines of communication with all parties involved to ensure relationships are not strained. By providing defensible and accurate evidence to providers, Cotiviti facilitates successful recoveries for clients even when high-dollar overpayments are at stake.

Benefits

Save an additional 0.25–0.3 percent on medical spend

Customize claim reviews to investigate unidentified billing compliance issues

Ensure a positive provider experience through fully validated findings and detailed communication

Safeguard your proprietary information with a neutral partner

Find high-value errors with an adaptive solution

Successful overpayment recovery requires experience, scalability, innovation, and proven value. Cotiviti has spent more than 20 years fine-tuning our solutions to deliver exceptional value to clients not only in overpayment recovery, but throughout the entire claim payment life cycle.

Rather than one-size-fits-all, Cotiviti’s Payment Data Validation solution can be aligned with your individual business goals. We precisely target the areas of operations that are most likely to yield positive recovery results and enable plan-specific flexibility, such as provider communication, provider reimbursement rules, or state requirements. Using both deterministic and predictive algorithms, our approach evaluates the value-potential and the probability of recovery when prioritizing work.

Clients receive ongoing guidance and support for the selection and approval of recovery concepts, performance reporting, and any appeals. And on a monthly basis, Cotiviti’s team will introduce new payment concepts and deliver root-cause analysis to help increase the value of health plans’ payment programs.

  

Identify overpayments across all lines of business with holistic data evaluation

Payment Data Validation can be applied to many claim types and areas of spend including inpatient, outpatient, and professional claims. The solution also factors in specific claim intricacies such as incongruent timelines, duplications with multiple providers or members, and complex pharmaceutical form fields.

Our audit teams go beyond standard automation to perform deep content reviews, applying a logic-based approach to dozens of audit reports, edits, corrected bills, late charges, and more until the full story of an episode of care is illuminated. Equipped with this information, our specialists can confidently decide on the correct allowable amount.

  

Feel confident with proven results

By adding human expertise and ancillary data sources to our best-in-class analytics, Cotiviti’s Payment Data Validation solution delivers highly accurate findings that minimize abrasion and any burden on health plans’ internal teams.

That’s why Cotiviti is a trusted partner for five of the six largest commercial plans, as well as managed Medicaid plans across 39 states.

 

Results we have delivered include:

More than $300 million in overpayments identified and recovered in 2019

A minimal 2–3 percent overturn rate when findings are appealed

>90 percent accuracy achieved with our validated findings

  

Examples of Payment Data Validation concepts:
Core Concepts

Duplicates

  • Multiple claims/providers/members

Outpatient/Physician

  • Excessive units/charges
  • Global surgery
  • CPT procedures (NCCI/MUEs)

Pharmacy

  • Excessive units/charges
  • Drug frequency
  • Diagnosis-based dosing
Advanced Concepts

Multiple Claim Payments

  • Split bill/interim billing

Advanced Pharmacy

  • NDC/HCPC conversion

Inpatient

  • Maternity/well-baby
  • Neonatal LOC/birth weights

Physician

  • Advanced CPT coding
  • Behavioral health

Outpatient/Ancillary

  • Observation
  • Outpatient to inpatient/split bill

Reach out to one of our representatives for a presentation of our full list of concepts.

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