Cotiviti , a leader in data-driven healthcare solutions, is expanding its Clinical Chart Validation (CCV) solution and Prospective Accuracy claim review offerings with a new prospective chart review module. This adds pre-pay validation to Cotiviti’s rigorous process for inpatient diagnosis-related group (DRG), short stay, and readmission reviews, making it the most comprehensive end-to-end inpatient claim review solution available today.

“At Cotiviti, we have consistently empowered our clients to prevent inappropriate claim payments whenever possible rather than embarking on an often-difficult and costly recovery process,” said Emad Rizk, M.D., chairman, president, and CEO of Cotiviti. “As leaders and innovators in the payment integrity space, we are continuing to enable health plans to move more retrospective payment programs forward in the claim payment process by launching prospective Clinical Chart Validation. This solution is the first of several new offerings that build upon our successful prospective Payment Policy Management and Coding Validation solutions, which have been delivering significant savings to our clients for many years.”

Clinical chart review is a resource-intensive process that requires reviewing hundreds or even thousands of pages of information to validate that key diagnoses and procedures on claims are properly supported. Until now, the market has relied largely upon post-pay review, which generally recovers fewer than 70 percent of identified overpayments and often causes provider abrasion.

Cotiviti’s CCV solution goes beyond standard post-pay coding and documentation review to find more value by addressing inappropriate claims before payment. Cotiviti’s clinical and validation specialists leverage retrospective results, based on a client’s specific claims and provider behaviors, to configure client systems with the optimal mix of claims to review prospectively and select the charts with the highest probability of overpayment earlier in the process. Retrospective chart change rates average 30 to 35 percent, with prospective change rates expected to exceed 70 percent.

By utilizing a powerful combination of market-leading prospective and retrospective technology, advanced analytics, artificial intelligence, and real-world expertise, Cotiviti’s solution meaningfully impacts selection rates, change rates, and sustainability rates that lower provider abrasion. Direct physician involvement in reviews and appeals also sets Cotiviti apart—physician medical directors lead an auditing team of registered nurses and credentialed coding experts with an average of 20 years of clinical experience. They apply best practices, clinical insight, and intelligence across the claim lifecycle, from chart review through claim resolution. This comprehensive approach results in nearly twice the savings as other options, with an average 96 percent sustainability rate of claim decisions across all clients.