Self-funded health plans face all the same cost pressures—inflation, greater chronic care incidence, and sharply increased utilization—as fully funded plans. But when it comes to using payment integrity to ensure correct payment of claims, they can trail behind, especially if they’re not working with a third-party administrator (TPA) that offers payment integrity services. The need to ensure medical claims are paid appropriately and reduce administrative waste has become paramount for self-funded employers, with plan sponsors increasingly demanding transparency and greater accountability for cost containment from their TPAs.  

As the industry leader in prepay claim review, Cotiviti has been providing payment integrity services to health plan clients for 20+ years.

With the growth in self-insured plans, Cotiviti extends this value to TPAs as well, enabling them to offer their clients the extra layer of payment integrity that claim systems and primary claim editors are not designed to handle.

Tapping into these services, one of Cotiviti’s large health plan clients has been able to increase its medical cost savings by executing prepay editing on its self-insured group claims. After contracting with Cotiviti for prepay claim review and clinical auditing in 2020, the organization added claim review for self-funded groups in 2023. 

Today, self-funded group savings make up 40% of what the client realizes annually and medical cost savings have increased by $28 million. The organization has found success with Cotiviti’s prepayment claims editing by working through the administrator-employer contracting process, landing on opt-out arrangements, which includes payment integrity as part of a standard package of services during contracting for all participating groups. 

Key results*

$28M Annual medical cost savings from self-funded groups

40% Portion of savings from self-funded group business

6M Member lives covered by all Cotiviti's benefit administration clients

Key benefits for TPAs and self-funded clients

• Avoid payment errors before claims get paid
• Lower administrative costs by reducing “pay and chase”
• Maintain positive provider relationships while ensuring payment integrity 

Key Cotiviti differentiators

• Highest incremental savings value in market
• Designated clinical consultant team
• Integrated prepay automated editing and clinical coding review 

*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.