Get More Bang for Your Buck:

Adjusting Prepay Approaches to Match

the Changing Landscape
Setting a strategy to keep up with dynamic payment models

June 25, 2019

Objectives and Key Themes

In this discussion you will…

• Understand how an inefficient data exchange partnership could be
resulting in unrealized savings opportunities
• Hear examples of trending payment integrity policy in the market
• Learn recommended practices to increase payment accuracy and savings
while minimizing provider abrasion

Key Themes
• Longitudinal data is foundational to best practice approaches we
recommend
• Savings are realized when payment policy is coupled with client data quality
and continued expansion
• Successful payment policy expansion requires effective provider
communication and measurement

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  2

A Word About Cotiviti Pre-pay
Optimized data exchange enables interoperability of Cotiviti payment integrity services

Appropriate Determination
• Ongoing process to help our clients make
informed, data-driven, clinically-centric
decisions on payment policy
Accurate Administration
• Assuring that payment policy is configured
and applied with an outcome that is
consistent with the client’s intention
Effective Support
• We provide substantial support to our clients
to assure the sustainability of their policy
decisions within their organization; this
includes:
o Prospective claim editing
o Provider communication tools
o Analytics / business decision support
o Fraud, Waste and Abuse reporting
o Clinical Validation service
o Retrospective claim review service

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  3

Data Exchange is an Industry Opportunity
Recent Market Research

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  4

Match Your Data Pipeline with Policy Advancements
to Capture Unrealized Savings
• Data availability
o How long has it been since you have had a substantive conversation about data exchange?
o Undertake a holistic review, not tactical
• Data ingestion
o Have vendor methods changed over the years? Have your internal methods changed?
• Data and knowledge transfer for adjacent product categories of value
o Same-day nurse review of claims, which we call Clinical Validation
o Fraud, waste and abuse monitoring
o Retrospective coordination of benefits and data mining for claims paid outside of contract
terms and billing policies
o Are you including your internal data partners in payment integrity discussions?
o Truly partner with data experts in your organization to speed changes
and cascade value opportunity

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  5

Benefits of a Holistic and Planned Data Exchange Review

• New policy opportunity discovery and selection

o Help your IT department help you by participating in the review and forecasting demand.
o Eliminate the need for frequent disruptive tactical data exchange adds balanced against
other important IT initiatives
o Create a recurring data exchange review with your client team
o Plan for an internal initiative in partnership with your IT department to modernize data
exchange of plan data with partners, plan the frequency of future reviews

• Enable value realization through a comprehensive claims data feed through pre pay
o Know your options of other solutions your data exchange can support
o Smart selection is available depending on your pace of expansion
• Maximizing your data increases the accuracy of payment policy through contextual history
• Your providers and members will benefit as full member history provides a more accurate
member record and adjudication experience
• Full data set enables product capabilities of the merged companies
• Analytics: additional data supporting research and development of new opportunity

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  6

Increase Accuracy and Savings
Find strategies within data exchange to keep pace with advancements in prepay

We view the value provided is in direct proportion to the comprehensiveness of the

data exchange between the health plan and their pre pay partner
• Completing the longitudinal data view of claims exchange with Professional,
Outpatient and Inpatient data enables savings opportunities…
o Cross claim policy capabilities to provide a full member contextual claims review
o Greater accuracy for our clinical Nurse logic reviewers of claims with our newly
available linkage to our Clinical Validation service from Prepay
o Geographic marker inclusion to provide accuracy down to zip code for policy
o We see an increased reliance on NPI to serve as a common identifier in policy
practices
o National Drug Classification (NDC) code validity and inclusion to map to appropriate
HCPCS

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  7

Analytics and Insights / New Opportunity
Analysis of trends and insights leads to new payment policy opportunity

Emergency Room E&M Recode Policy Example

• Data analysis to identify spikes, then trends in ER E&M Levels of Service
• Resulting in new policy to help rein in cost associated with inappropriate coding

% of Facility ER Claims by Level of

45%
Service TBA 2013 to 2018
40%

35%

30%

25%
Steady
20% increase in
High Level
Use of Low ER visits
15%
Level ER visits
is decreasing
10%

5%

0%
% Level 1 % Level 2 % Level 3 % Level 4 % Level 5
2013 2014 2015
2016 2017 2018 thru June 30

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  8

Provider Communication

The successful implementation of any

new medical policy should include
detailed provider communication Cotiviti
supports you with…

o Supporting product memorandum or talking points

o This material is shared with your operations personnel and provider network for education
and also to assist in provider communication materials developed for your network
o Some examples of recommended provider communication practices
 Joint development of a payment policy notice to providers
 Development of FAQs that present from your operations or provider network
 Health plan Provider Bulletins & Information with the information
o Importance of education to your providers to reduce abrasion, and where you need
assistance to speak to your client team who can reach out to product as needed

9
© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY 
Call to Action

Identify areas of opportunity along with your vendors.

• If you are a Cotiviti client, reach out to conduct a gap analysis of your data exchange
with us.

Ask yourselves
• What areas of savings are you missing out on due to aged data exchange with Cotiviti
or another vendor?
• Do you have a team dedicated to vendor data exchange? Is it a two way street?
• Prioritize data exchange updates and strategies to refresh with your IT department 

We would like to hear from you your thoughts and ideas on future data
exchange to channel our development efforts towards.

Contact Cotiviti (email)

© 2019 Cotiviti, Inc. CONFIDENTIAL AND PROPRIETARY  10

THANK YOU