Medical pharmacy data mining innovation uncovers significant findings for large national plan

Regulatory changes, prompt pay laws, and differing provider contractual terms can frequently lead to contract compliance issues, often resulting in inaccurate provider billing practices. While black-and-white claim coding mistakes can generally be solved using automated prepay solutions, more complex claim issues generally require advanced postpay investigation and analysis.

A large, multi-state managed care organization faced significant difficulties in optimizing its medical pharmacy and contract compliance programs, leading to inaccurate claims payments. With a diverse membership and a complex network of healthcare providers, the plan needed a reliable partner to improve performance across its core prepay and postpay programs, with a specific focus on data mining to resolve complex claim issues.

Delivering results with innovative medical pharmacy solutions

At the start of Cotiviti’s partnership with the plan in 2012, prepay solutions uncovered inconsistencies in billing, leading to the need for additional program support from Cotiviti’s postpay solutions, including clinical chart review, coordination of benefits (COB), and data mining. Data mining was further enhanced by adding contract compliance efforts, with Cotiviti gaining access to provider contracts to ensure adherence to complex payment contractual terms.  

After adding postpay data mining and contract compliance in 2023, the team worked closely with the plan to identify high-value and complex medical pharmacy payment and contractual errors.

These programs leveraged pharmacy benefit manager (PBM) data to identify cross-benefit drug duplicates—cases where the same medication is inadvertently paid for under both the medical and pharmacy benefits. This enhanced focus led to a $1 million increase in overpayment findings as Cotiviti’s experts introduced new specialty concepts for the plan's review and approval.

Continued collaboration on medical pharmacy audits uncovered excessive charge errors, including $1.6 million in incorrect rates and invoice costs, as well as $1.3 million in unauthorized overpayment requests for medications not listed on the plan’s preferred drug list. Through targeted medical pharmacy innovation efforts, Cotiviti has identified over $3.8 million related to large medical pharmacy contract compliance findings for 2025 year-to-date. 

The collaborative approach between the payer and Cotiviti has identified opportunities to optimize current programs, which are under review and have the potential to yield significant additional savings moving forward. The client has supported Cotiviti’s findings, enabling continued innovations that deliver substantial recovery results year-over-year. 

Key results*

$206M in medical cost reduction for 2024

$724M net savings on improper claims since 2020

101% of findings goal achieved with data mining

Key benefits

• Investigate unidentified billing compliance issues

• Achieve projected savings of an additional 0.6% on medical spend

• Gain positive provider experience through fully validated findings and detailed communication

• Safeguard proprietary information with a neutral partner

Key Cotiviti differentiators

• Customizable, dynamic library of concepts for unmatched accuracy, breadth, and depth
• Managed service model flexes for quick changes and frequent updates without extra cost 
• SaaS architecture and rules engines allow customization to advanced concepts and contract terms
• Designated teams guide and support through concept assessment, selection, customization, reporting, and recovery support
• Ability to identify savings within 8-12 weeks from a valid data file pull
• High-quality findings with a 97% sustainability rate

*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.