Effective clinical chart reviews are an integral part of any payment integrity program. Inpatient diagnosis related group (DRG) claims are particularly prone to inaccurate billing, but typical pay-and-chase efforts can result in unhappy members, increased administrative costs, and provider abrasion.
The challenge
A large national health plan with commercial, Medicare, and Medicaid lines of business (LOBs) wanted to capitalize on market best practices by adding prepay functionality as an extra layer to their existing DRG auditing program in the fall of 2023. A successful Cotiviti payment integrity partner of nearly 25 years, the client was looking to increase the value of its DRG audits, building on the success it enjoyed with Cotiviti’s postpay Clinical Chart Validation program starting with the commercial LOB.
Cotiviti worked hand-in-hand with the plan to scale and refine the program while bringing parity to both prepay and postpay, adding incremental value over time. Leveraging Cotiviti’s market-leading, AI-enabled chart selection methodologies, we ensured a focus on claims with the highest probability of overpayment. Pairing AI with human expertise, we select the right claims at the right intervention point for the greatest savings, shifting left when appropriate, leading to a notable 42% change rate for the client*.
The results
In the first year, the client realized a 45% increase in overall program value, with 35% of cost avoidance shifting from postpay to prepay, plus 15% net-new prepay value. In addition, it took 128 fewer days per claim to realize value in prepay than in postpay, on average.
Since that time, Cotiviti remains focused on innovating and expanding the prepay program to increase value, with more savings, better shifting to prepay efforts, and lower provider abrasion through minimal appeals. As the project continues, adjustments are made as necessary with mindful scaling, and the program continues to deliver solid results. Confidence in the program has led the client to expand it quickly, adding Medicare and Medicaid LOBs in 2026.**
Key results include:
- 45% increase in program value in one year alone
- 128 fewer days to realize value in prepay than in postpay
- Very high appeal sustainability at 99% with addition of prepay
Key solution benefits
- Cotiviti’s market-leading, AI-enabled chart selection methodologies ensure a focus on claims with the highest probability of an overpayment
- Highly trained clinicians and coders work with clients to shift the right concepts and claims from prepay to postpay
- Realistic opportunity analysis and goal-setting leads to trust, partnership, and continued growth
Key takeaways
- Connected prepay and postpay efforts with intention and collaboration
- Lower MLR and ALR with saved administrative costs and efforts by shifting to prepay
- Improved, net-new recoveries
*42% of the claims we have audited for the client have resulted in an overpayment finding.
**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.
