Health plans face a major challenge in acquiring valid and accurate member data to coordinate benefits in a timely manner. Overpayments can happen when information gaps develop between members, providers, employers, and payers. Unfortunately, payment integrity programs often do not have the bandwidth, data analytics, and industry expertise to maximize their cost-savings potential in this specific area.
Cotiviti’s Payment Responsibility solution delivers deep and broad coordination of benefits (COB) determinations. We provide thorough review and analysis of contracts, eligibility files, third-party benefits agreements, and other data sources to determine COB and payment responsibility. We target members with a high probability of Medicare coverage using custom analytics, validate eligibility with Medicare, and work with providers to refile claims with Medicare. Our 20+ years of expertise in this specific area allows us to identify complex COB issues beyond any payment integrity vendors and programs that our clients may have in place. From this identification process, we build a store of comprehensive eligibility data and analytics that identify other commercial payer responsibilities.
Go beyond existing payment integrity vendors and programs to identify complex COB issues
Analyze more members and claim types, spanning across all medical products
Identify members with a high probability of Medicare coverage or other commercial coverage using proprietary analytics
Uncover high-value overpayment findings through a combination of analytics and subject matter expertise
We use precision analytics embedded within your payment integrity program to deliver unique overpayment findings, looking at more claim types than industry peers and digging deeper. The COB audit concepts we target include Medicare dual eligibility; age, end-stage renal disease (ESRD), and disability entitlement; commercial, Medicare, and Medicaid coverage; maternity; newborn enrollment; and retiree benefits. Our automated COB tracker ensures that once identified, a coordination case is corrected in your payment system and claims are paid correctly going forward.
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. Our experts can help you make the most of our analytics, providing high-quality results that minimize your own resource use.
Cotiviti applies a combination of advanced analytics and the expertise of clinically experienced professionals to review complex scenarios that often slip through audits, which allows us to deliver differentiated results to our clients. We are a trusted partner to five of the top six health plans in the country, and offer a proven track record of providing significant incremental savings.
More than $40 million in cost savings generated for managed care organizations in 2017, including specialty drugs covered under medical benefits
More than 80 percent of overpaid findings on average collected and realized as cost savings