A large payer with commercial, Medicaid, and Medicare lines of business was failing to meet its targeted medical loss ratio (MLR), specifically within the Medicare business. The major assumption for this miss was a latent demand in surgeries and procedures paired with an increase in more acute membership.

As a long-time client of Cotiviti’s Payment Policy Management claim editing solution, the payer had access to insights from cross-payer analytics that individual payers can’t glean from within their own data. Our expert analytics team—with the help of benchmarks derived from a blinded claim data set including 23 of the top 25 payers in the country—proactively provided reports on:

• Key Medicare utilization and unit cost trends, including a comparison to peer payers
• Top CPT-level spend drivers in each spend category
• Top ICD-10 groups affected
• Geo-mapping of regions with the strongest trends
• Benchmark comparisons of payment policy usage and payment integrity performance for peer payers

"Cotiviti's analytics are unparalleled and there’s no better way to see benchmarks on how we compare against peers." — VP, Payment Integrity

Through engagements between Cotiviti and the payer’s clinical and business leaders, the client identified three specific categories of spend that represented a combined utilization increase of more than 10% and a unit cost increase of more than 15%. Furthermore, Cotiviti helped pinpoint payment policies to implement to help mitigate the runaway costs, supported by contextual data showing that other payers in the region were already implementing those policies. The client then developed a plan to turn on additional payment policies, including emergency room E/M over-coding.

Key results*

• Projected $73 increase in PMPY savings by preventing improper claim types highlighted in the analytics

Key benefits for clients

• Contextualized insights that go beyond internal data 
• Intelligence to inform payment integrity decisions
• Benchmark-backed medical cost savings opportunities

Key Cotiviti differentiators

• Unparalleled data set from nearly 2/3 of the U.S. insured population
• Advanced analytics and decision-support tools
• Trusted clinical and strategic experts to partner with clients

*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.