Medical Intelligence

Gain insights into every facet of healthcare utilization


The facts

Although the U.S. healthcare system continues to face the turmoil of competing priorities and approaches, the desire to control escalating costs through greater efficiency remains constant. The key to efficiency is effective risk identification, stratification, and management.

To succeed in managing population-based clinical and financial risk, payer organizations need answers to highly complex questions about healthcare costs, quality, and utilization. Use of advanced data analytics leads to the efficient, accurate discovery of critical business performance insights.

Medical Intelligence combines Cotiviti’s industry-leading DxCG science, evidence-based clinical quality rules, healthcare utilization metrics, and claims-based HEDIS measures to enable payers to manage risk and target opportunities for improving healthcare results. Users can easily stratify and segment populations (by risk, costs, utilization, predicted future cost, or location), access member-level detail (e.g., conditions, comorbidities, clinical events, gaps in care, prescription compliance), and evaluate efficiency and performance by program, provider, and more.


For population health management, Medical Intelligence helps:

  • Identify high-risk members in need of immediate or long-term clinical intervention
  • Pinpoint those at risk for hospitalization or emergency room (ER) use in the near future
  • Optimize the results and operational efficiency of outreach and engagement initiatives

For clinical program design and evaluation, Medical Intelligence helps:

  • Analyze population and member-level conditions, gaps in care, quality, and compliance metrics
  • Monitor and measure the progress of disease management and wellness programs and vendors
  • Identify new intervention programs needed to address conditions driving cost and utilization

For network management, Medical Intelligence helps:

  • Assess the impact of out-of-network utilization
  • Inform pay-for-performance, accountable care, and other alternative quality contracts

For medical cost management, Medical Intelligence helps:

  • Analyze utilization patterns to identify waste and drive appropriate use of medical resources
  • Identify conditions and members driving costs and utilization patterns

Broad utility for power users and generalists alike

Medical Intelligence helps payers, providers, employers/brokers, third-party administrators, and others meet several critical goals:

  • Performance trending: find opportunities in the complex interplay of healthcare cost, quality, and utilization data
  • Population risk identification and stratification: organize and prioritize any population with speed, accuracy, and superior predictive power using DxCG Intelligence, the industry’s gold standard in risk adjustment and predictive modeling for decades
  • Individual-level clinical insights: drill down to gain insights into each healthcare consumer that drive the most effective interventions
  • Provider performance assessment and network management: identify key trends at the provider level that drive more effective collaboration with your provider network in quality improvement and other initiatives
  • Ad hoc data integration and reporting: take a deep dive into data discovery and visualization to deliver enhanced reporting


Flexible design and reporting

Cotiviti makes creating your own dashboards simple with Vital Instant Insight Widgets (VIIWs), preconfigured charts that answer commonly asked questions about healthcare cost, quality, and utilization. We also help clients jump-start their analytics with standard dashboards (e.g., Emergency Department Visit).

In addition to a broad range of powerful pre-built analytics, Medical Intelligence users can query their data in a variety of ways:

  • Claims Search: build a query for a claims extract
  • Stratifier: identify the right members for intervention, track them over time, and evaluate the success of their care management programs, all while effectively managing the programs themselves
  • Health risk assessment refinement (optional): pinpoint cohort groups based on lifestyle choices, family history, lab values, biometrics, and other HRA data

Users have access to both standard and customized reports, as well as the ability to autogenerate and distribute these reports on a specified schedule.

Organizations looking for enhanced visualization and reporting capabilities can add Enterprise Intelligence, a component of Medical Intelligence that enables power users to dive deep into data discovery and visualization, leveraging online analytical processing (OLAP) technology.

The gold standard in risk adjustment and predictive modeling

At the heart of Medical Intelligence is DxCG Intelligence, the gold standard in risk adjustment and predictive modeling. Part of healthcare’s DNA for 20 years, DxCG Intelligence uses Cotiviti’s proprietary predictive models to turn healthcare data into risk scores for individual patients and identify the primary drivers of risk. Scores correlate with the cost of the underlying illness burden that individuals carry. Aggregating the scores of individuals with key attributes generates group-level predictive results that can be applied to answer questions fundamental to the ability to manage clinical and financial risks.

Nearly 500 organizations use DxCG Intelligence, which provides a common language of risk adjustment for healthcare payers and providers, for employers, for government agencies, and for academic researchers investigating ways to improve healthcare administration and delivery.

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