An effective payment integrity program goes beyond relying on manual models and targeting low-hanging fruit—yet many payment integrity solutions on the market offer just that. Payment integrity programs should aim for better total value, thinking long-term to consider the components that can decrease medical cost, meet a sustainable administrative burden, and keep members satisfied. The ideal payment integrity program will enable plans to process out complex claims in a timely manner, leveraging technology and clinical expertise to meet the specific needs of your plan ..read more

In February, the proposed changes announced in the 2025 Medicare Advantage (MA) and Part D Advance Notice released by the Centers for Medicare & Medicaid Services (CMS) allowed plans to prepare for updates to payment factors impacting their risk adjustment and quality programs before official notice of set rates. With the publication of the Final Rate Announcement, payments to MA plans include up to a 3.70% increase on average, or over $16 billion compared to 2024—the same as CMS proposed in the Advance Notice, despite industry advocates arguing that a higher rate increase is warranted. F ..read more

Health plans face a major challenge in acquiring valid and accurate enrollment data to coordinate benefits in a timely manner. The complexity of coordination of benefits (COB) makes overpayments more likely to occur when information gaps develop between plans, which can increase the burden on internal resources. The evidence for the effectiveness of retrospective review is strong—but recovering funds after payments are made is an intricate and tedious process. By combining retrospective COB with prepay review, plans can increase value by catching errors before claims are paid ..read more

Amid rising medical loss ratios, administrative cost pressures, and increased competition, health plans are under pressure to deliver high-performing payment integrity programs. But when choosing between a software-only payment integrity vendor versus a full-service partner, health plans have many factors to consider when it comes to their prepay claim review, DRG validation, coordination of benefits, and data mining programs. On the third episode of our Payment Integrity Insights podcast, Cotiviti’s payment integrity leaders discuss: The dimensions of payment integrity value that go beyond ..read more

Enabling health plans to effectively capture their members’ risk requires innovations as well as in-depth industry expertise. Faced with the increasing complexity of evolving guidelines, regulations, and new technologies entering the scene, plans should identify core strengths that ensure stability, scale, and consistent quality while driving innovations that create value. Meet us at RISE National 2024 to discuss how to improve risk adjustment performance and results. During our roundtable discussion, Best practices and new approaches to drive value, on Tuesday, March 18 at 4:50 pm CT, we’ll ..read more

Each year, the National Committee for Quality Assurance (NCQA) publishes a list of measure updates, additions, and deletions for future HEDIS® measure years for public comment. For Measurement Year (MY) 2025, NCQA has proposed adding five new measures, revising five existing measures, and making additional updates related to gender inclusivity and race-ethnicity stratification. The organization has also shared finalized changes to expect for MY 2025 that are not up for public comment. Here, we offer a summary of NCQA’s proposed changes as the organization seeks feedback from health plans by M ..read more

Risk adjustment presents a multifaceted challenge to health plans due to its complexity and frequently changing regulatory requirements, shifts in population health, and more. How can payers strengthen their programs by recognizing where to prioritize attention and budget? I invite you to join Cotiviti for a RISE webinar on Thursday, February 29 at 1:30 pm ET as we uncover key risk adjustment trends to watch in 2024 and beyond. We will deliver an in-depth understanding of key industry and regulatory trends and discuss best practices that are necessary to drive change, optimize impact on opera ..read more

The annual Centers for Medicare & Medicaid Services (CMS) Advance Notice stands as the beacon guiding Medicare Advantage (MA) payers through the methodological changes shaping the Star Ratings program and more. As MA plans sift through this nearly 200-page document to digest key updates, gain an expert perspective on some of the changes that matter most from Cotiviti’s quality team.  Launching this Thursday, February 22 at 1 pm ET, Cotiviti’s Quality Decoded webinar series will deliver guidance on how to navigate the intricate landscape of healthcare quality reporting and empower inf ..read more

The signing of the 21st Century Cures Act in 2016 was a long-awaited milestone for interoperability in healthcare—yet with so many regulations and other key details left to be determined after the fact, 2023 was when interoperability’s true promise finally began to emerge. Here are three key updates for payers to track as the Trusted Exchange Framework and Common Agreement (TEFCA), which was established by the Cures Act, comes to life in 2024 ..read more

In the final quarter of 2023, scrutiny reveals a notable resurgence in instances of fraud, waste, and abuse (FWA). These cases, affecting both public and private payers, have demonstrated a persistent use of deceptive tactics ranging from kickbacks and falsified claims to exploitation of healthcare programs for Native Americans. Here is a compilation of some of the most significant FWA cases to make the news from October to December 2023.  ..read more