Our capabilities

A unique approach to unlocking value

Our clients know that to achieve administrative, operational and financial goals, they need to take into account every input in the payment cycle. That’s why Cotiviti Healthcare offers a uniquely comprehensive set of capabilities that reflects our view of payment accuracy as a wide-ranging strategic activity.

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Cotiviti Healthcare solutions achieve accuracy both prospectively and retrospectively to ensure that coding is correct, and our clients are billed in accordance with their payment and medical policies. Continual monitoring enables up-to-date policy compliance, supported by a robust policy library, deep research and clinical expertise so that policy determinations across plans are consistently accurate and comprehensive.

Cotiviti’s constantly updated content library spans government, industry and medical board recommendations and guidance – thousands of policy changes that Cotiviti researches, manages and applies for our payer clients. Cotiviti Healthcare combines this content with leading research, expertise and guidance in policy decisions from medical and coding experts.

We drill into the details of each payment, cross-checking claims against the specifics of differing provider contracts to avoid inappropriate payments. This helps achieve greater accuracy in an environment of increasingly complex contractual arrangements, enabling our clients to better manage changes in the healthcare system.

Cotiviti Healthcare solutions draw on multiple data sources to increase payment accuracy. We thoroughly review and analyze contracts, eligibility files, third-party benefits agreements, and other data sources to determine payment responsibility and coordination of benefits.

Using a combination of technology-enabled analytic filtering, automated processes and the expertise of highly qualified clinicians, Cotiviti Healthcare reviews medical charts for correct coding and proper documentation to determine whether claims are supported, and whether care was delivered in accordance with industry standards and payer guidelines.

Cotiviti Healthcare combs through claims data to uncover signs of improper provider billing and coding, and reveal broader client and industry trends. This provides us and our clients the insight needed to reduce future instances of waste. We can also manage reconciliation, working directly with payers to document and support claim decisions and recover overpayments. Using analytics and data mining, we can assess opportunities for improvement in the payer’s processes, policies and provider network that hold the potential to reduce administrative costs.


 

The strength of our analytics-driven offerings arises from a team of full-time, dedicated doctors, nurses, claims coders, forensic auditors and other experts, all focused on ensuring that claims are paid accurately according to each health plan’s policies and agreements. Our team of specialists also monitors hundreds of medical and payment policy content sources to develop algorithms and concepts that incorporate the latest standards.

Our capabilities integrate seamlessly into the payment cycle, complementing existing processes without hampering payer operations. The Cotiviti Healthcare team complements and adds value to the payer’s internal resources, helping to address key issues and capture opportunities for improvement.