Healthcare payers face increasingly complex fraud, waste, and abuse (FWA) risks that are evolving faster than traditional controls and recovery efforts can keep pace. Pay-and-chase models often review individual events in a vacuum, limiting their ability to identify larger, systemic issues before improper payments occur. To preserve the affordability of care, plans need stronger prevention models that detect risky patterns earlier, strengthen oversight, and help stop FWA before it spreads.
A regional health plan working with Cotiviti uncovered significant waste and abuse risk after Cotiviti’s Claim Pattern Review™ solution identified a provider for prepayment review.
By analyzing 12 months of billing data, Cotiviti detected suspicious billing patterns and helped the plan take action before additional improper payments occurred. Cross-payer analysis allowed the plan to identify systemic issues, expanding the scope and creating more possible savings.
The plan needed a proactive way to evaluate suspicious provider billing behavior and determine whether the services billed were supported by medical records. An in-depth examination of the provider’s medical records revealed that nearly every reviewed record failed to support the billed services, resulting in a 100% error rate on flagged claims. A 70% technical denial rate resulted from the provider's failure to submit requested medical records within required timeframes, while an 85% uphold rate indicated that most denials remained valid after appeals and later record submissions.
After identifying concerns with the provider, Cotiviti compared findings across other participating health plans to determine whether similar outlier billing patterns existed elsewhere. A cross-payer analysis helped reveal potentially systemic issues that would not have been visible from a single payer's data alone.
Key results*
- >$500k in recovered payments
- 100% error rate revealed on flagged claims
- 85% uphold rate after appeals and later record submissions
Key solution benefits
- Expanded visibility into potentially systemic billing behavior through cross-payer analysis
- Identified unsupported billing before additional payments were made
- Strengthened provider oversight through medical record review and defensible denial decisions
Key differentiators
- Cross-payer visibility that helps identify provider behavior patterns beyond a single health plan’s data
- Full-service solution including review by highly qualified SIU analysts
- Rules, analytics, and SIU analysis continuously updated by Cotiviti’s cross-continuum payment solutions
Want to prevent waste and abuse before claims are paid? Learn how Claim Pattern Review™ can flag providers that warrant immediate investigation.
*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.
