Identifying excessive units in medical pharmacy billing is a complex challenge faced by many health plans. Dosing guidelines from regulatory bodies such as the FDA can vary widely based on specific medical indications and individual patient characteristics such as weight, age, and gender. This variability makes it difficult to define clear billing limits, and providers may submit claims that fall outside of these recommended guidelines. As a result, efficiently and accurately flagging excessive billing becomes a significant operational hurdle for payers seeking to ensure payment integrity.
In 2012, a large national health plan partnered with Cotiviti to enhance its payment accuracy efforts, beginning with prepay and expanding to postpay solutions, including advanced data mining to identify high-value and complex medical pharmacy errors. In collaboration with the client, Cotiviti deployed advanced machine learning models to prioritize the review of billing errors based on probability. By integrating the client’s full dataset, member and provider billing histories, and customized calculated fields, Cotiviti was able to uncover smaller, high-priority opportunities, research new areas to reduce overpayments, and eliminate false positives more effectively.
Following the implementation of Cotiviti’s machine-learning driven solutions for detecting excessive units in medical pharmacy claims, the client experienced a more than threefold increase in both identified overpayments and claim volume compared to previous methods—resulting in a significantly accelerated time to recovery. These results demonstrate Cotiviti’s ongoing commitment to innovation and responsible deployment of artificial intelligence, consistently achieving recovery results within budget and delivering high-quality outcomes for health plans of all sizes—all under the oversight of clinical experts.
Key results*
- >3X increase in identified overpayments for client
- 253% increase in overpayment findings per hour**
- >$2.5B in overpayment findings in 2025**
Key benefits
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Accelerate the recovery process
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Uncover and address previously unidentified billing compliance concerns
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Realize additional projected 0.6% medical cost savings
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Enhance provider satisfaction through thoroughly validated findings and detailed communication
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Protect proprietary data with a neutral third party
Key Cotiviti differentiators
- Customizable, dynamic library of concepts for unmatched accuracy, breadth, and depth
- Managed service model flexes for quick changes and frequent updates without extra cost
- SaaS architecture and rules engines allow customization to advanced concepts and contract terms
- Designated teams guide and support through concept assessment, selection, customization, reporting, and recovery support
- End-to-end services to convert findings into recoveries and insights
- Highly accurate, validated findings that yield 97% sustainability
- Trusted data mining partner for >20 years
Future-proof your payment integrity programs
By partnering with Cotiviti, payers benefit from a highly adaptable platform that delivers both immediate and long-term value—leveraging advanced customization, rapid deployment, and expert support to tackle emerging challenges. With Cotiviti’s innovative payment integrity solutions spanning the full claim payment spectrum, health plans can achieve sustainable cost savings, minimize abrasion, and stay ahead of regulatory and market changes, securing a strong foundation for future success.
*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.
**Across all Data Mining clients.
Interested in learning more about preparing your payment integrity strategy for the future? Read our eBook, Future-proofing payment integrity to learn how to set your plan up for success.
