Payment Policy Management

Increase payment integrity and save up to 3% or more on annual medical spend


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Healthcare payers are under constant pressure to deliver fast payment despite the system’s complexity. Managing infrastructure, improving healthcare accessibility and quality, perfecting hundreds of processes, and staying current on claims payment policies? It can be overwhelming.

of surveyed Payment Integrity VPs, Directors and Managers at payer organizations are likely to recommend Cotiviti.*


But Cotiviti’s Payment Policy Management solution is here to help.

Get tailored support and significant savings from an industry leader in payment rules development and knowledge. Our Payment Policy Management solution helps payers tailor, test, and execute best-practice clinical and payment policies, ensuring compliance and averting incorrect payments. Using reference assets and clinical research acumen, we identify payment vulnerabilities and develop industry-compliant payment rules—decreasing improper spend and saving millions.

Our unique approach to prepay claims editing saves payers millions of dollars every year, even in addition to their primary editing systems. Results we have delivered for individual clients include:


in total annual net savings


estimated savings from professional and institutional claims

Low rates

of provider appeals and inquiries

Payment Policy Management solution benefits

Savings are just the surface—working with Cotiviti ensures a number of different benefits, including:

  • Decreased provider abrasion. Cotiviti provides a six sigma level of accuracy of 99.93% (measured by administering policy according to client wishes). Serving 100+ payers—including 21 of the top 25—means our services are familiar to nearly all networks.
  • Customization and flexibility. Our technology-enabled editing services are tailored per client, whether to suit the best practices of the mid-market, or to accommodate mature, complex operating environments.
  • Reduced waste. The solution is a vital tool in identifying and reducing paid claims stemming from errors, waste, and abuse.
  • Less time on claim inquiries. Provider communication inquiry support tools allow for more provider self-service and quick, clear, and consistent communication of edit recommendations.
  • Low IT and administrative burden. Our technology integrates with multiple claims platforms and there’s no need to install hardware/software or costly updates—we release updates automatically.
  • Unparalleled support. Cotiviti provides dedicated support to ensure the sustainability of policy decisions for each client. This includes provider communication tools; analytics and business decision support; policy evaluation and selection; and a claim inquiry tool that supports payment policies' application in the claim adjudication process.

*Source: TechValidate. TVID: C2C-86D-FD0

Manage payment integrity with the experts

Our database of policies is comprehensive, up-to-date, and defensible, all rigorously reviewed by our medical directors, certified professional coders, and expert panels. They’re 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. We also facilitate policy assessment and selection, which includes a client-centered review and decision-making process tailored to each client.

A few example policy areas that benefit from our dynamic rule updates and deep clinical foundation include:

  • Professional and Emergency Department facility evaluation and management
  • Durable medical equipment
  • Institutional claims
  • Drugs and biological claims

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