Preventing improper claim payments not only helps to reduce wasteful out-of-pocket costs for members and to lessen provider abrasion—it can also help a health plan remain competitive.
That's why one mid-sized health plan with just over 500,000 members views success in prepay editing as a prerequisite for competing in the market among its regional peers.
As a long-time Cotiviti Payment Policy Management and Coding Validation client, this payer has built and maintained a comprehensive library of policy edits to tackle more clinically complex claims for second-pass editing after primary editing is complete.
Due to the mature nature of the policies in place and commitment from leadership to reduce improper medical costs, the plan is experiencing strong annual net savings across its Medicare Advantage, commercial fully-insured, and commercial self-insured lines of business—all after primary editing. With these second-pass claim editing solutions in place, they are able to significantly prevent improper claims that are lower in dollar value but higher in volume.
The client is considering adding more prepayment integrity possibilities to address coordination of benefits and higher-dollar inpatient claim reviews in the near future.
Key results*
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1.6% annual medical cost savings from reduced improper payments
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>$124 PMPY reduction in improper payments for Medicare Advantage business
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>$90 PMPY reduction in improper payments for commercial business
Key benefits
- Increased prepay savings by avoiding improper claims payment
- Improved competitive position in marketplace
- Improved accuracy of provider payments
- Reduced provider abrasion
- Accelerated time to value
Key Cotiviti differentiators
- Highest incremental savings value in market
- Designated clinical consultant team
- Integrated prepay automated editing and clinical coding review
- Ability to add more complex review types in the future
*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.
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.
