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Cotiviti - Healthcare Payer BPS

Vendor Analysis

by Sven Lohse

published on May 17, 2019

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Report Overview:

In August 2018, the Waltham, MA-based Verscend Technologies company acquired Atlanta, GA-headquartered Cotiviti Holdings. In the future, the combined entity will operate under the Cotiviti name.

Who is this Report for:

NelsonHall’s profile of Cotiviti’s Healthcare Payer Business Process Services (BPS) is a comprehensive assessment of service offerings and capabilities designed for:

  • Sourcing managers monitoring the capabilities of existing suppliers to deliver business process services to healthcare payers
  • Vendor marketing, sales and business managers looking to benchmark themselves against their peers
  • Financial analysts and investors specializing in the support services sector.

Scope of this Report:

The report provides a comprehensive and objective analysis of Cotiviti’s offerings, capabilities, and market presence in support of business process transformation through the application of healthcare payer BPS including the company’s:

  • Offerings and key service components
  • Delivery organization
  • Customer base, including the company’s targeting strategy and examples of current contracts (where available)
  • Revenue estimates for healthcare payer BPS
  • Strategy, emphasis and new developments in support of healthcare payer BPS
  • Strengths and weaknesses.

Key Findings & Highlights:

In August 2018, the Waltham, MA-based Verscend Technologies company acquired Atlanta, GA-headquartered Cotiviti Holdings. In the future, the combined entity will operate under the Cotiviti name.

Cotiviti is a private company and does not release revenue data. NelsonHall estimates that the revenues of the combined Verscend and Cotiviti businesses for commercial healthcare payer clients for BPM contracts in 2018 were $52m. NelsonHall estimates that these revenues (compared with those of the two formerly separate companies ) grew 6% from those of the prior year from $49m.

NelsonHall estimates that revenues from government clients in 2017 and 2018 were $20m, associated mainly with the Medicare fee for service Recovery Audit Program (RAC).

Cotiviti now serves healthcare organizations including payers, brokers, providers, government agencies, and employers. For healthcare payers, its primary customer segment, Cotiviti aims to help minimize clients’ medical loss ratios using data and analytics to realize better clinical outcomes and greater efficiencies in the provision of care.  Cotiviti offers particular expertise for healthcare payers cross the following lines of business: medical, dental, pharmacy and professional/outpatient. In terms of business function, Cotiviti expertise includes:

  • Quality and compliance, especially clinical quality metrics, e.g., HEDIS scores
    • Quality intelligence
    • Star Navigator
    • Medical record retrieval
    • Medical record abstraction
    • Medical intelligence
    • DxCG intelligence
  • Claims administration, especially payment integrity (including clinical coding) and fraud, waste, and abuse
    • Claim accuracy (coding error detection)
    • Special investigations unit services
    • Predictive and prospective analytics
  • Risk adjustment
    • Commercial
    • Medicare
    • Medicaid.

Cotiviti’s employs medical coders (approximately 1,000) that support its claims and payment integrity services. Cotiviti employs a similarly sized contingent to support software-based services for payers.

Software-based services are based on the following products:

  • Quality Intelligence – analytics and reporting
  • Star Navigator – Star ratings optimization and reimbursement forecasting
  • Medical record services – retrieval and abstraction
  • Medical intelligence – provider profiling, risk identification, and population health profiling.

Cotiviti personnel are typically located off the client premises but within the U.S.

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