Case study: Accelerating value-driven care through provider specialty tiering

Leading health plans know that to stay competitive and meet the demands of the members and employer groups they serve, they must proactively increase the value of care they provide while decreasing costs. That’s why one major health plan in North Carolina, serving nearly 4 million members across the state’s 100 counties, took action in recent years to implement a provider specialty tiering program that helps guide members toward higher-performing, lower-cost providers using Cotiviti’s Network Intelligence Risk-Readiness® provider scoring system.

“One of the reasons we were excited about Network Intelligence is that it is well established and nationally accepted. Claims-based metrics are challenging for payers and providers, particularly when it comes to specialties,” said the plan’s medical director. “For example, HEDIS® measures are oriented toward primary care and are mainly process measures. There aren’t many specialty-specific measures. Using Network Intelligence opened the door to evaluating other specialties.”

Download our case study and learn:

  • How the plan developed its tiering program with input from providers
  • How the tiers were created based on quality, cost, and network value/efficiency scores
  • How Cotiviti’s Network Intelligence solution measures provider value in a fair and transparent way


Read the case study



Mac Davis
Mac is the director of solution design at Cotiviti and has extensive experience working with payer and provider organizations to strategically optimize the delivery of high-value care and alternative payment models.

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