Payment Policy Management

Identify millions of dollars in prospective payment savings


The facts

The healthcare ecosystem faces enormous pressure to develop, operate, and maintain expansive infrastructure to continually improve healthcare accessibility and quality. At the same time, complex U.S. healthcare billing and payment processes pressure physicians to be expert medical practitioners and payers to perfect hundreds of functions and processes. The cost and time to develop the expertise in one of those functions, such as payment integrity, can overwhelm payers. And with the vast network of physicians caring for plan members’ individual needs, staying current with ever-evolving claims payment policy changes is difficult.  

Cotiviti’s Payment Policy Management solution enables payers to make informed, data-driven, clinically centered decisions on payment policy. Our unique insights leverage extensive reference assets and clinical research acumen to help us identify potential payment vulnerabilities and develop industry-compliant, effective payment rules. And our comprehensive policy recommendations apply across all provider settings and lines of business.


Avoid payment errors before claims get paid

Validate accuracy

Identify and address claim discrepancies

Alleviate the burden of payment policy management

Unique capabilities that drive client value

Payment Policy Management helps clients tailor, test, and execute best-practice clinical and payment policies, ensuring compliance to avert or recover incorrect payments. We help payers address the strategic needs and operational opportunities associated with effective payment policy management. Our solution helps healthcare clients validate accuracy and identify and address claim discrepancies immediately following claim adjudication and before a claim is paid. Our process includes appropriate determination, accurate administration, and effective support.

Appropriate determination is our ongoing process to help clients make informed, data-driven, and clinically focused decisions on payment policy. We leverage a robust library of payment policies with a deep clinical foundation that includes evaluation and management, professional, durable medical equipment, outpatient facility, National Drug Code (NDC), and drugs and biologicals. Our policies are comprehensive, up-to-date, and defensible, based on more than 100 sources, including American Medical Association (AMA), national and regional Centers for Medicare & Medicaid Services (CMS), national specialty services, and state Medicaid guidelines, all rigorously reviewed by our medical directors, certified professional coders, and expert panels. We also facilitate policy assessment and selection, guided by our medical directors and coders through a data-driven approach with client-specific insights. This includes a client-centered review and decision-making process with integrated market customizations and flexibility.

Accurate administration uses configuration of payment policy decisions and their accurate and consistent application to ensure payment policy is configured and applied to gain an outcome consistent with the client's intent. Cotiviti applies customization to reflect each client’s unique needs. Our flexible application addresses product and geographical differences, while frequent releases align with the dynamic nature of coding guidelines. We also provide ongoing payment policy management to ensure accurate and consistent application. In addition, our contextual processing considers historical and current claim data elements.

Finally, Cotiviti provides substantial and dedicated support to each client to ensure the sustainability of policy decisions within the organization. This includes provider communication tools; analytics and business decision support; policy evaluation and selection; fraud, waste, and abuse reporting; and a claim inquiry tool that supports payment policies application in the claim adjudication process.

Feel confident with proven results

Cotiviti applies payment policies from the industry’s most comprehensive correct coding and medical policy content library, giving payers access to the most current research on payment policies in the industry. With unmatched technology designed specifically to apply these policies with flexibility, we can customize an approach to meet a payer’s specific needs and ensure the client is in control of paying claims accurately.

We process more than 597 million claims and 1.3 billion claim lines  on behalf of our clients.


Results we have delivered include:

$2.3 billion in total annual net savings

1 to 2 percent estimated savings from professional claims

0.5 to 1.5 percent estimated savings from outpatient claims

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