Each year, $600 billion in U.S. healthcare spending goes to unnecessary care and other inappropriate payments, driving up overall costs without returning real value to the system. To create meaningful change, payers and providers must collaborate in the definition and pursuit of high-value care, in which providers make the most efficient and judicious clinical choices that deliver the best patient outcomes and save systemic costs. In exchange, providers should be rewarded for their efforts.
Cotiviti’s Network Value solution helps payers and providers collaborate to create and manage value-based healthcare delivery and payment. We enable an innovative new approach to medical economics that helps clients recognize and reward high-value care while eliminating low-value care and other unnecessary payments from the healthcare system. We take payers through the high-value journey, socializing and educating providers about value. Then, we put data into action and incentivize change.
Drive down the total cost of care
Increase revenue through more informed market expansion and network optimization
Enable payer and provider collaboration in high-value care programs executed through multiple payment structures
Identify and reduce low-value care from inefficient and unnecessary services
Encourage members to make wise caregiver choices
To begin the high-value journey, clients must first understand what “value” really means. Cotiviti offers a proprietary methodology for calculating what is considered to be high-value care, using the Dartmouth Atlas, Choosing Wisely, and other academic research as well as Medicare claims data (Parts A, B, and C).
We then benchmark providers across their geographic and specialty peers to identify those who are most likely to succeed in risk-based arrangements. Clients can recognize and reward high-value care while eliminating low-value care, allowing them to build and optimize high-performing networks, enable provider collaboration, transition from volume to value, and drive down the total cost of care.
The power of perspective
Cotiviti combines more than 100 different publicly available data sources with our own data to create powerful benchmarks that payers can use to encourage high-value care. Our data sources come from:
Cotiviti examines and grades each provider, then compares him or her with others in the client’s network. With the data assembled, clients can tier and sculpt their networks, share this information with members, and create strategies to steer them toward higher value providers—which has a significant and positive impact on value and cost for everyone.
Network providers tend to operate on a bell curve. Through education and data, Cotiviti reveals their practice patterns. How do they practice, how do they refer, and how can we give them better data to make better choices? Cotiviti spends the time to educate clients so they better understand their current networks and where their value lies.
Next, we help payers collaborate with their providers to create lasting change. We educate and inform providers, showing them how their practice patterns compare with their peers’ and what they can do to become a high-value performer. We reduce the administrative burden for high-value providers with tools such as gold-star programs, audit exclusion, or no prior authorizations. In addition, we build high-value referral pathways to direct more members to high-value providers.
Transparency accelerates provider buy-in
Cotiviti uses open data and open methods to create its scores. Because we use public data, we can obtain data for 90 percent of physicians in a given geographic area.
Payment must be tied to value or change will not occur. Cotiviti helps clients think through and implement payment programs at scale, in real time, and virtually on a claim-by-claim basis.
Through policy-driven payment programs, we incentivize high-value care by shifting payment from low-value to high-value providers. Through the development of specialist programs, we incentivize high-value care across providers that often exhibit significant unwarranted practice pattern variation. And through the development of primary care programs, we incentivize high-value care within existing programs.
With providers ranked by value, clients can influence choice of providers. This information can be highlighted in provider directories and benefit design. Cotiviti enables organizations to generate data-driven awareness campaigns and offer shared decision-making to help guide informed choices.
RowdMap Risk-Readiness® Platform
Payers can use this platform to access RowdMap analytics, benchmarks, and reports.