Healthcare claims must align with a myriad of best practice payment policies and nationally accepted coding standards to ensure appropriate payments. But these complex policies and coding standards can create challenges for health plans that result in high-dollar overpayments. While overpayments to providers are common, health plans need strong analytics and targeted research to aid answers for recovery and reduce overall mistakes.

Beginning in 2014, a large Blue Plan partnered with Cotiviti after facing significant challenges in ensuring healthcare claims aligned with best practice payment policies and coding standards, often leading to high-dollar overpayments. In seeking a solution, the plan looked for strong analytics and targeted research to aid recovery without impacting critical provider relationships.

Taking an incremental, targeted approach

Cotiviti employed a tailored approach to Data Mining, aligning with the plan’s specific business goals and targeting high-value overpayment areas. This approach leveraged over 2,000 concepts and reports to deliver exceptional value. When Cotiviti proved to be a trusted partner, the plan provided full access to its claim data system, resulting in 25% lower void rates on average.

The client then expanded its data mining program with Cotiviti by adding medical pharmacy concepts, including pharmacy benefit manager (PBM) duplicates, which increased pharmacy recoveries by 7%, and Rx provider outreach, which increased pharmacy recoveries by 25%.

The plan also added administrative services only (ASO) group data review to the data mining program, leading to a 1% increase in total recoveries for ASOs. As self-funded plans continue to proliferate, it is crucial for health plans to apply payment integrity to these groups to avoid financial losses. Without such measures, increased enrollment in ASO groups could reduce medical cost savings.

Cotiviti additionally supported the client in recouping inappropriate payments caused from a Medicare pricing issue. As a result, the client saw an 18% average increase in total recoveries. The plan has reaped the benefits of customized claim reviews, with projected savings of an additional 0.50% on medical spend, and a positive provider experience through validated findings. 

Key results*

$64M In total recoveries over the course of the partnership

7% Increase in pharmacy recoveries after adding PBM duplicates review

25% Increase in pharmacy recoveries after adding Rx Provider Outreach

Key benefits

• Customized claim reviews to investigate unidentified billing compliance issues
• Positive provider experience through fully validated findings and detailed communication
• Safeguarded proprietary information with a neutral partner
• High-quality findings with a 97% sustainability rate

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
• True collaboration and access to shared insights with the ability to identify savings within 8-12 weeks from a valid data file pull

*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.