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.
Beginning in 2014, a regional 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.
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.
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$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 |
Cotiviti isn’t just a name in healthcare payment integrity—we’re your strategic partner in delivering real results. Our tailored Data Mining solution goes beyond buzzwords, driving measurable financial recoveries and operational efficiency. With a holistic approach to claim payment accuracy, we help your pre-payment and post-payment integrity teams cut through the noise and achieve greater medical cost savings, reduced abrasion, and lower administrative burden. It’s not hype—it’s high-impact performance.
*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.