In recent years, health plans have made significant progress in moving their payment integrity strategies from postpayment correction and recovery to catching inappropriate claims before payment occurs. But as healthcare costs continue to rise and the demands for cost savings increase, payment integrity programs have become increasingly layered, nuanced, and complex.
No longer is the payment timeline simply thought of as “before payment” or “after payment”—instead, it’s more of a connected claim continuum, where each claim must be processed at the right intervention point to deliver the highest value and the lowest abrasion.
Ultimately, a robust payment integrity program rests on three core pillars:
- Determining responsibility: This means seeing each member within their own context and paying claims accurately across the member’s journey—with no member abrasion.
- Ensuring accuracy: This means correcting inappropriate claim coding while validating other suspect claims against medical records, contract terms, and other data.
- Detecting patterns: This means deploying advanced analytics and seasoned expertise to look for patterns of fraud, waste, or abuse that can escape detection within a claim-by-claim review.
I invite you to watch our new video above explaining Cotiviti’s approach to helping you meet these three critical goals. You’ll learn how we’ve been able to deliver more than $7 billion per year to our clients in payment integrity savings—with as much as 80% of that savings occurring before payment.