payment integrity

E&M over-coding: How can payers solve this costly challenge?

Evaluation and Management (E&M) services comprise a significant payment integrity challenge, costing individual payers millions or even tens of millions of dollars in inappropriate claim spend per year, depending on their size. And the problem appears to be getting worse over time. Cotiviti’s analysis of paid claims over the past five years shows a particularly …

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Execute healthcare claims editing more accurately—with less provider abrasion

Claim editing is generally a health plan’s first line of defense within its prospective payment integrity (PPI) program. It’s a practice based on following guidelines and rules from organizations like the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) and codifying them into claim editing rules—so how hard can it …

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Panel Webinar: Right payment integrity intervention, right time

An enterprise payment integrity strategy spanning the prepay and postpay continuum is essential to effective claims processing, provider relations, and cost savings. Healthcare payers have begun an earnest transition from postpayment to prepayment methodologies. But to maximize payment integrity savings and reduce provider abrasion, payers must find the optimal balance for their business. I invite …

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Podcast: Cotiviti CEO Emad Rizk, M.D. on payment integrity and interoperability

Achieving true payment accuracy and eliminating waste in healthcare requires not only ensuring that claims are billed and paid appropriately, but also factoring a patient’s risk profile and quality outcomes into healthcare payments. That was one topic of conversation as Cotiviti CEO Emad Rizk, M.D., joined The Incrementalist host Dr. Nick van Terheyden for a …

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The right payment solution at the right time: 3 takeaways from Cotiviti’s new research

Preventing an inappropriate claim from being paid in the first place versus recovering an overpayment after the fact is always the ideal approach for health plans—but in many cases, this simply isn’t possible. For example, identifying fraud or abuse typically requires health plans to retrospectively analyze patterns of paid claim behavior to identify the aberrance, …

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Webinar: Integrating pre and postpay programs for optimal FWA results

Bad actors continue to be a problem in healthcare, finding new ways to take advantage of organizations and patients every day. But as the industry continues to fight fraud, waste, and abuse (FWA), new approaches are emerging that use both current data and past results to apply the right prepay action to the right FWA scenario.   On May 25, join Cotiviti for our webinar, “A …

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Keeping members in mind: Optimizing coordination of benefits

Coordination of benefits (COB) requires health plans to navigate significant complexities. The order of benefit determination rules rely on an ever-changing member landscape that is as variable and unique as the members themselves. It can be easy, therefore, to forget to put the claims lifecycle in context against the actual member experience—getting a new job, …

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Webinar: Improving coordination of benefits with a member-centric approach

Health plans of all sizes often struggle to acquire valid and accurate member data to coordinate benefits in a timely manner. And unpredictable circumstances, such as major illness or job loss, impact how coordination of benefits (COB) rules are applied and often create gaps in information between members, providers, employers, and payers. This can create …

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Podcast: A better approach to clinical appropriateness in claims payment

Are you asking the right questions when determining whether your claims are clinically appropriate? For example, were the diagnoses billed supported by clinical indicators in the records? Was the correct clinical setting assigned and billed based on nationally recognized guidelines? The process of reviewing claims and charts for clinical appropriateness is crucial for your business as you look to curb improper payments and reduce fraud, waste, …

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