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Large Medicaid payer protects taxpayer dollars, financial integrity with prepay review

Serving low-income members who often face challenges related to health equity and social determinants of health, Medicaid plans face some of the greatest difficulties in healthcare. Not only do they typically operate on thin margins, they also have an obligation to protect the funding they receive from taxpayers by staying vigilant against inappropriate expenditures. With the latest reported Medicaid improper payment rate reaching 5.09% according to the Centers for Medicare & Medicaid Services (CMS), Medicaid plans are also particularly vulnerable to inappropriate claims submitted by bad actors looking to exploit their members and their payment policies.

That’s why one Cotiviti client, the largest Medicaid payer in the state it serves, partnered with Cotiviti beginning in 2013 by adopting Payment Policy Management for second-pass prepay claim editing in addition to Cotiviti’s postpay Clinical Chart Validation DRG review. As the plan’s membership has grown, it has also added fully integrated Coding Validation for prepay review of complex coding errors, in addition to increasing its adoption of new payment policies within Payment Policy Management to improve claim accuracy.

While the plan has realized significant claim payment accuracy improvements and medical cost savings due to its adoption of prepayment integrity solutions, the client sees Cotiviti’s service model as the primary differentiator over other vendors, forming strong, collaborative relationships with client medical directors to support appeals and other challenges that arise.

The plan has also worked closely with Cotiviti to improve data mapping and adjust payment policy exclusions and bypasses to improve its payment integrity results.

Key results*

$227M

annual cost reduction for 2024

79%

of savings delivered prepay

>23%

savings growth since 2020

Key benefits

  • Increased prepay integrity by avoiding improper claims payment
  • Improved provider payment accuracy
  • Closed gaps in primary claim editing
  • Ability to rapidly scale payment integrity programs with membership growth

Key Cotiviti differentiators

  • Collaborative and responsive service model that drives continuous growth
  • Industry’s most comprehensive coding and medical policy content library
  • Payment policies informed and constantly maintained by clinical expertise
  • Commitment to expert-driven technological innovation
  • Trusted partner of choice with 20+ years of proven success delivering these solutions to 60 payers including 25+ with Medicaid line of business

Perform beyond silos with the right payment integrity partner

As health plan claim volumes grow amid cost increases and changing guidelines, the opportunity for inappropriate claims to slip through the cracks and get paid grows, too. Especially when plans use a siloed and disconnected approach to payment integrity. Learn how Cotiviti's Payment Accuracy suite helps you knock down those silos by shortening time-to-results from more than 90 days to less than five with an integrated pre and postpayment program. 

Learn more about Payment Accuracy solutions

*The results depicted are based on an individual client’s experiences and circumstances. Results may vary depending on factors including but not limited to usage and application.