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Blue Plan expands Cotiviti DRG review program amid early success

Performing effective clinical chart review to support payment integrity requires a targeted, analytics-driven approach. Rather than casting a wide net, health plans must concentrate on pursuing only the medical records that are most likely to contain errors. Otherwise, they run the risk of provider abrasion while wasting valuable administrative resources.

After adopting Cotiviti’s prepay Payment Policy Management and Clinical Validation solutions in 2021, one regional Blue Plan expanded its relationship with Cotiviti in 2023 by adding Clinical Chart Validation to support first-pass DRG review for its Medicare Advantage line of business. Upon implementation, Cotiviti performed a 12-month backsweep, reviewing claims from the prior year. This immediate lookback enabled the plan to correct overpayments from the prior year, delivering a strong early return on investment. In fact, overall program findings ($5.4 million in 2024) have tripled the original projections presented to the plan.

Within a year, the success of the Medicare Advantage pilot led the client to expand the programs of business, including Medicaid populations while looking forward to adding commercial.

The plan specifically praised Cotiviti’s responsiveness—both in day-to-day interactions and in customizing program nuances to fit its needs. In addition, the plan has found that Cotiviti’s findings are easy to defend with its provider network.

Key results*

54%

of claims audited by Cotiviti result in overpayment finding

100%

of claims selected for record review approved by client

3X

of original projected findings achieved

Key solution benefits

  • AI-enabled chart selection helps ensure that only charts with a high likelihood of yielding a finding are requested for review
  • Broad clinical review capabilities including DRG, short stay, readmissions, skilled nursing facility (SNF), and inpatient rehabilitation facility (IRF) delivers better ROI
  • 99% sustainability means nearly all of Cotiviti’s findings deliver value back to the plan

Key takeaways

  • Start smart, scale fast: Beginning with one line of business allows you to prove the value before expanding enterprise-wide.
  • Trust matters: A strong, responsive partnership and defensible findings can significantly improve provider relations.
  • Leverage AI for accuracy: Targeting the right charts maximizes impact while minimizing provider abrasion.
  • Backsweeps drive early ROI: Reviewing prior claims captures immediate savings potential.

Perform beyond expectations with Clinical Chart Validation

Cotiviti’s pre and postpay Clinical Chart Validation solution empowers payers to find more value with less administrative burden and provider abrasion, helping them protect their resources to foster improved care. Read our fact sheet and learn how Cotiviti is the only partner to provide a comprehensive program of complex prospective and retrospective claim reviews of inpatient DRGs and postpay reviews of outpatient, skilled nursing and inpatient rehabilitation, short stay, and readmission claims.

Read the fact sheet

*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.