As healthcare utilization and per-unit costs continue to rise, health plans are looking to tighten their payment integrity programs to minimize inappropriate payments while protecting their members’ plan benefits. These efforts range from automated prepay editing of black-and-white payment scenarios to sophisticated postpay analysis of complex medical pharmacy concepts—and everything in between.
Here are three examples of Cotiviti clients of varying sizes that have worked diligently to perform beyond expectations in payment integrity.
Mid-sized health plan: Prioritizing prepay integrity
Payment integrity doesn’t just protect a health plan and its members—it’s increasingly vital to staying competitive. That’s one reason why a mid-sized health plan with just under 500,000 members uses Payment Policy Management for automated claim editing paired with Coding Validation for more clinically complex claims. See how the plan has reduced medical costs by more than 3.5% by decreasing improper payments across both Medicare Advantage and commercial lines of business.
Regional Blue Plan: Deploying data mining
Ensuring that healthcare claims align with best practice payment policies and coding standards is a challenge for payers of all sizes. That’s why one regional Blue Plan has taken an incremental approach to its data mining program, adding new medical pharmacy concepts such as pharmacy benefit manager (PBM) duplicates and Rx provider outreach to increase recovery of inappropriate payments. See how a customizable, dynamic library of concepts and true collaboration have enabled the client to recover over $64 million in overpayments, delivering better results for the plan’s members.
Large national payer: Validating coordination of benefits (COB)
Outside of basic eligibility verification, COB has traditionally been a postpay-only process for payers, requiring significant administrative effort and expense to recover overpayments. That’s why a large national payer adopted Cotiviti’s prepay COB Validation solution, implementing a “pause-and-review” approach to prevent inappropriate payments from being made in the first place. After launching in one market, the client swiftly moved to expand the program to several other states, with innovation and collaboration driving success. See how a robust prepay-to-postpay feedback loop and consultative support have enabled the client to realize more than 99% of identifications as cost savings achieved by preventing inappropriate payments.
Cotiviti was recently designated the highest in the Leader Category by Everest Group in the Payment Integrity Solutions PEAK Matrix® Assessment 2025. Read the Everest Group report on Cotiviti’s Payment Accuracy solutions and see how this recognition reflects our continuous innovation, commitment to accuracy, and proven success in delivering value to clients.
