Cotiviti Blog

RISE highlights connected data, early intervention

Amanda Liu — Wed, 01 Apr 2026 14:39:45 GMT

RISE National 2026 brought together health plan leaders, policymakers, and industry partners to examine how Medicare Advantage is evolving in the face of rising costs, regulatory scrutiny, and growing expectations for better outcomes. From risk adjustment and data integration to AI and compliance, the conference underscored a shared priority across both payers and providers: turning accurate data into better decisions and better care. Here are five key themes emerging from RISE that are expected to play a pivotal role in health plan operations in 2026 and 2027.

eBook: Future-proofing payment integrity

Warren Lesnefsky — Wed, 25 Mar 2026 13:30:00 GMT

Healthcare spending continues to climb, and the pressure on health plans to manage costs without disrupting providers or members has never been greater. With improper payments persisting and medical loss ratios (MLR) and administrative loss ratios (ALR) increasing, payment integrity has emerged as one of health plans’ most powerful tools. But today’s fragmented, reactive approaches to payment integrity are no longer enough. Health plans must come together to shift processes to the left, unite prepay and postpay efforts, and leverage AI effectively.

In our new eBook, Future‑proofing payment integrity, we explore why plans must rethink how and when they intervene across the claim lifecycle.

FWA Insights: Identifying adult day health billing schemes

David Kaahaaina — Wed, 18 Mar 2026 13:46:19 GMT

Adult day health (ADH) programs are intended to support vulnerable populations, including older adults and adults who require supervision during the day. But improper billing practices, noncompliance with state age requirements, and potential patient recruitment schemes highlight the need for increased payer vigilance against fraud, waste, and abuse (FWA). In fact, throughout 2025 and into 2026, Cotiviti’s own investigators observed a rise in questionable billing patterns among ADH providers, particularly involving basic and enhanced service levels.

In this edition of FWA Insights, we examine how Cotiviti’s investigators identified outlier providers, what their analysis uncovered, and how health plans can strengthen oversight of ADH billing.

Webinar: Inpatient claim review trends and challenges

Amy Carleton, RN, BSN — Mon, 16 Mar 2026 17:12:01 GMT

As commercial group medical costs are expected to rise nearly 9% in 2026, health plans are contending with an increasingly high‑stakes challenge: ensuring inpatient claims are paid accurately in an environment where clinical scenarios, coding behaviors, and utilization patterns are rapidly shifting.

Inpatient stays remain one of the most expensive categories of care, and the inherent complexity of clinical documentation, DRG assignment, and medical record review means that errors can easily go undetected. In fact, many plans still bypass inpatient claim editing altogether because of that complexity, leading to millions of dollars in preventable overpayments and significant operational strain downstream.

HEDIS MY 2027 Public Comment: What to know

Samantha Davis — Tue, 10 Mar 2026 18:19:46 GMT

Each year, the HEDIS^® public comment period offers health plans a critical opportunity to understand what’s changing and to influence what comes next. For Measurement Year (MY) 2027, the National Committee for Quality Assurance (NCQA) is proposing a wide range of updates that span finalized measure changes, updates still open for comment, and several new measures that signal the continued shift toward digital and outcomes‑focused measurement. Simultaneously, the Centers for Medicare & Medicaid Services (CMS) is proposing measure retirements and additions for the Exchange MY 2026 Quality Rating System (QRS) reporting program.

Below is a concise breakdown of what health plans need to know now, and how to prepare for what’s ahead.

Webinar: Decoding the HEDIS MY 2027 public comment period

Samantha Davis — Wed, 25 Feb 2026 13:42:00 GMT

Each year, the National Committee for Quality Assurance (NCQA) releases proposed updates, additions, and retirements to HEDIS^® measures for future reporting years. These updates play a central role in shaping quality strategy, impacting everything from clinical workflows and data capture to the way health plans report, improve, and communicate performance.

Improving medical record retrieval: 5 best practices

Amanda Liu — Thu, 12 Feb 2026 19:29:18 GMT

As the healthcare industry adapts to rapid regulatory shifts, financial pressures, and evolving provider networks, health plans must optimize their approach to clinical data retrieval for risk adjustment and quality gap closure to remain efficient and compliant.

Here, we explore five best practices to enhance retrieval success, improve outcomes, foster collaboration, and enhance value—without increasing provider burden or placing strain on internal teams.

FWA Insights: The top fraud schemes of 2025

Erin Rutzler, AHFI, CFE, CHC, CPC — Tue, 10 Feb 2026 15:33:12 GMT

Throughout 2025, federal and state authorities uncovered schemes involving everything from unnecessary lab tests to fraudulent telehealth services and hospice care. These cases highlight the evolving tactics bad actors use to exploit vulnerabilities—and the urgent need for payers to stay vigilant. While the methods vary, the goal is the same: profit at the expense of patients and payers.

In our latest edition of FWA Insights, we break down three major categories of FWA—lab testing, home health and hospice, and telehealth—with real-world examples from 2025 and recommendations for mitigating these risks.

2027 CMS Advance Notice: 4 key updates

betty.stump@edifecs.cotiviti.com (Betty Stump, MHA, RHIT, CPC, CDIP) — Thu, 05 Feb 2026 16:13:18 GMT

On January 26, 2026, the Centers for Medicare & Medicaid Services (CMS) released the 2027 Medicare Advantage and Part D Advance Notice. This annual publication outlines proposed payment and policy updates that will shape the landscape for Medicare Advantage (MA) and Part D plans next year.

In the latest notice, CMS offered three specific principles guiding changes to the risk adjustment model: simplifying administrative burden for both payers and providers, increasing competition to create value for patients, and driving accurate payments. For MA professionals, particularly in risk adjustment and quality, understanding these changes is crucial for optimizing plan performance, ensuring compliance, and maintaining a competitive edge. Here are four key updates to consider and recommended strategies.

Webinar Series: Mastering risk adjustment essentials in 2026

Katie Sender, MSN, RN, PHN, CRC — Tue, 03 Feb 2026 15:07:26 GMT

Risk adjustment is a strategic, constantly evolving field at the heart of healthcare transformation, and 2026 is no exception. As risk adjustment leaders continue to navigate changes, they face important challenges and opportunities, including growing cost pressures, accelerating technological progress, and increased scrutiny.

Stay ahead throughout 2026 with Cotiviti’s Risk Adjustment Essentials webinar series as our experts provide timely insights for industry leaders, spotlighting the trends, innovations, and best practices shaping risk adjustment throughout the year. Register for the series to start the year with a strong foundation, gain a better understanding of evolving regulatory practices, and learn how to build a sustainable framework to drive compliant results.

FWA Insights: Preventing overbilling in therapeutic home services

Mary Cate Hay, AHFI, HCAFA — Mon, 26 Jan 2026 14:30:00 GMT

The risk of overbilling for therapeutic services remains a pressing concern for health plan special investigative units (SIUs) and compliance teams. Excessive or inappropriate billing not only drives up costs but can also undermine the integrity of care delivery. Identifying outlier procedure codes—like those billed at unusually high rates compared to peers—is a vital step in detecting and preventing fraud, waste, and abuse (FWA). By leveraging data analytics and targeted investigative practices, health plans can pinpoint these outliers and safeguard payment accuracy for home health claims.

Webinar Series: Decoding quality throughout 2026

Branka Sustic — Wed, 21 Jan 2026 16:01:34 GMT

Healthcare quality programs are undergoing rapid transformation. As regulatory expectations grow more complex and measurement methodologies continue to evolve, quality and Stars teams are under increasing pressure to stay informed, agile, and compliant—while still improving outcomes for members. Keeping up with ongoing changes from the Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) is essential to maintaining strong performance, financial stability, and improved member outcomes.

To support health plans navigating this shifting landscape, Cotiviti is announcing the return of Quality Decoded, our most popular webinar series, beginning February 24, 2026. Designed specifically for payer quality and Stars program management professionals, Quality Decoded breaks down complex changes while offering practical strategies aligned to the moments that matter most throughout the year. From proposed rulemaking to finalized policies and performance results, this series helps your team understand what’s changing, why it matters, and how to respond with confidence.

3 key payment integrity trends to watch in 2026

Megan Brennan, CPC, CPCO, CPMA, CFE — Tue, 13 Jan 2026 19:24:48 GMT

As healthcare regulations and utilization patterns evolve for 2026, payers face significant changes that will impact reimbursement strategies and fraud, waste, and abuse (FWA) prevention. Confirmed and proposed federal regulations have introduced permanent telehealth flexibilities, new remote patient monitoring codes, and sweeping updates to skin substitute reimbursement and DMEPOS accreditation. These changes create opportunities for improved care delivery but also new challenges in compliance and FWA management.

Here are three key shifts for payment integrity and compliance teams to monitor as the new year gets underway.

Star Ratings reset: How MA plans can prepare

Marge Ciancetta — Tue, 16 Dec 2025 16:24:58 GMT

As the 2025 calendar year closes out, Medicare Advantage (MA) leaders are continuing to evaluate the potential impact of a proposed rule released by the Centers for Medicare & Medicaid Services (CMS) that would significantly reshape the MA and Part D Star Ratings program. Here, we break down the most impactful changes, evaluate how they would impact overall Star Ratings outcomes, and offer recommendations for MA plan leaders to consider in their 2026 and 2027 strategies.

Checklist: Creating a comprehensive risk adjustment program for the new year

Amanda Liu — Wed, 10 Dec 2025 13:30:00 GMT

Health plans today face mounting pressure to modernize their risk adjustment strategies. With regulatory oversight intensifying and technology unlocking new possibilities, organizations must move beyond traditional methods and embrace a more proactive, integrated approach to stay ahead.

As precision becomes the new norm with updates like CMS-HCC Model V28 and the increased scrutiny of health risk assessments (HRAs), the healthcare continuum inches closer to real-time data capture. As such, digital transformation and AI are bringing risk adjustment closer to the point of care. These advances reduce administrative workload and improve data quality, but they also demand thoughtful planning and execution. Consider an action plan as healthcare organizations continue to navigate the new reality of risk adjustment.

FWA Insights: Billing for services not rendered

Heather Weible, CPC — Mon, 08 Dec 2025 15:22:55 GMT

Payment accuracy is a cornerstone of healthcare, ensuring that funds are allocated only for services provided to patients. But the complex nature of healthcare billing can open the door for fraud, waste, and abuse (FWA). With healthcare spending in the United States exceeding one trillion dollars each year, government agencies estimate more than $100 billion may be lost to fraudulent or abusive practices, including schemes in which providers bill for services not rendered.

The Centers for Medicare & Medicaid Services (CMS) considers billing for services that are not provided to be intentional and deceptive, describing it as one of the highest and most deliberate forms of fraud. But to catch such schemes, health plans must remain vigilant against bad actors.

Read on to learn how Cotiviti’s special investigations unit (SIU) uncovered and helped shut down a large-scale provider billing scheme, as well as best practices to identify and prevent future FWA.

Webinar: Upcoming regulations and their potential payment integrity impact

Warren Lesnefsky — Thu, 04 Dec 2025 16:39:25 GMT

The health insurance landscape is constantly shifting—driven by new regulations, guidelines, and policies that aim to balance consumer protection, innovation, and rising costs. These changes can significantly influence how payers operate, from reimbursement models to compliance requirements, and even the technologies they adopt to maintain efficiency.

For payers navigating such a complex environment, understanding the payment integrity implications of upcoming rules is not just important—it’s essential to avoid costly missteps and ensure continued alignment with industry standards. Staying ahead of these changes is critical to maintaining both financial stability and trust with providers and members.

Navigating the 2026 ICD-10-CM coding updates

Katie Sender, MSN, RN, PHN, CRC — Tue, 02 Dec 2025 13:45:00 GMT

The annual ICD-10-CM code set update, effective October 1, features new codes, revised guidelines, and editorial adjustments that require careful analysis and strategic implementation. Navigating the complexities of these coding changes is crucial for healthcare organizations aiming to optimize their risk adjustment programs. This also provides an excellent opportunity for collaboration and partnership.

Early preparation, collaboration, and continuous education for coding teams are all critical to reducing learning curves and ensuring accurate coding. Health plans need to be ready to review the latest ICD-10-CM updates and to adopt best practices to prepare, adjust, and thrive in the new year.

Podcast: An innovation roadmap for risk adjustment strategies

Kassi Yozzo — Mon, 24 Nov 2025 20:40:14 GMT

New dynamics in risk adjustment are prompting health plans to rethink their strategies for 2026 and beyond. With regulatory changes and evolving audit methodologies on the horizon, health plans are investing in prospective and concurrent approaches alongside their traditional retrospective programs to help ensure sustainability, improve coding accuracy, and strengthen compliance.

In a new episode of the RISE Radio podcast, senior leaders from Cotiviti and Edifecs offer strategies for building scalable risk adjustment technology initiatives while navigating rising business and regulatory pressures.

eBook: Setting up for coordination of benefits (COB) success

Evan Okulanis — Wed, 12 Nov 2025 13:45:00 GMT

A robust coordination of benefits (COB) program can be one of the most difficult elements for health plans to achieve in creating a stronger payment integrity strategy. As rising healthcare costs, increasing medical loss ratios (MLR), and the need to maintain member and employer satisfaction grow, COB can be an area of substantial savings and operational efficiency. Determining the correct order of benefits swiftly, accurately, and comprehensively can help plans in a number of ways: avoiding increased medical expenses, reducing administrative burden, and decreasing member dissatisfaction and provider abrasion.

The practical landscape of AI in payment integrity and VBP

Brett Arnold — Wed, 05 Nov 2025 18:46:07 GMT

Artificial intelligence in healthcare is maturing along a spectrum, ranging from targeted machine learning models to more ambitious projects aiming for broader cognitive capabilities. Narrow AI, which includes familiar techniques such as machine learning and natural language processing, is well established and underpins many current healthcare applications. Meanwhile, the industry continues to explore more generalized AI that could handle a wider variety of tasks traditionally reserved for human experts. While these ambitions fuel innovation, most healthcare organizations remain focused on concrete, incremental improvements to existing processes.

Deploying AI in real-world healthcare settings faces persistent challenges. Integrating new models with legacy systems, safeguarding patient data, and navigating an evolving regulatory framework require cross-functional teams and continued investment. Larger organizations have made better progress moving AI projects from proof-of-concept to production, but integration and security remain the top barriers. Data privacy and regulatory compliance are not simply hurdles, but priorities that shape how AI initiatives are designed and governed.

Here, we break down how Cotiviti, Edifecs, and our customers are applying AI to support two critical initiatives: payment integrity and value-based payment.

FWA Insights: Stopping “phantom providers” with prepay intervention

Erin Rutzler, AHFI, CFE, CHC, CPC — Mon, 03 Nov 2025 19:11:14 GMT

One of the most elusive fraud, waste, and abuse (FWA) schemes facing health plans today is the rise of “phantom providers.” These are entities that exist only long enough to submit fraudulent claims and disappear before detection. Phantom providers, also known as ghost networks, are often calculated, fast-moving, and sometimes international in scope. And as the experience of Cotiviti’s own special investigations unit (SIU) demonstrates, the most effective way to catch them is with prepay intervention.

2026 Star Ratings: What they mean and what comes next

Marge Ciancetta — Wed, 29 Oct 2025 16:40:56 GMT

With the Centers for Medicare & Medicaid Services (CMS) publishing the 2026 Star Ratings earlier this month, Medicare Advantage plans are looking to rapidly assess their performance and close care gaps before the calendar year ends. As measures and cut points continually evolve, understanding the nuances behind these ratings is critical for MA plans striving to deliver high-quality care and stay competitive in an increasingly difficult market. Here, we review the latest results, examine key measures and cut point impacts, and outline practical recommendations for boosting Star Ratings performance.

Case Study: Regional Blue Plan performs beyond hype with Data Mining

Kevin Laskey — Thu, 23 Oct 2025 13:15:00 GMT

Healthcare claims must align with a myriad of best practice payment policies and nationally accepted coding standards to ensure appropriate payments. But these complex policies and coding standards can create challenges for health plans that result in high-dollar overpayments.

Beginning in 2014, a regional Blue Plan partnered with Cotiviti after facing significant challenges in ensuring healthcare claims aligned with best practice payment policies and coding standards, often leading to high-dollar overpayments. In seeking a solution, the plan looked for strong analytics and targeted research to aid recovery without impacting critical provider relationships.

Webinar: Navigating 2026 coding updates for risk adjustment success

Katie Sender, MSN, RN, PHN, CRC — Tue, 21 Oct 2025 14:30:31 GMT

2026 is coming up fast and health plans should be preparing risk adjustment programs accordingly, with coding accuracy as critical as ever for securing appropriate reimbursement and supporting high-quality care. With ICD-10-CM updates and new trends approaching, preparing your teams and strategies for the new year is key.

Watch our on-demand webinar, 2026 Coding insights: Navigate latest changes and prepare for success. Join me and coding training and compliance manager Heidi Cantermen, CPC, CRC, as we dive into how to plan for 2026. We’ll share insights for health plan leaders to stay ahead of evolving regulations, anticipate impact on their coding programs, and drive documentation alignment across stakeholders to ensure accurate capture of members’ risk profiles.

Webinar: Decoding the 2026 Star Ratings

Marge Ciancetta — Fri, 17 Oct 2025 14:30:11 GMT

The recently published 2026 Star Ratings results confirm that even for large national payers, achieving and maintaining a rating of four stars or higher is no simple feat as measure requirements and cut points evolve from year to year. As it becomes harder for Medicare Advantage plans to achieve a high Star Rating and earn quality bonus payments, plans must quickly evaluate their performance, identify gaps, and implement strategies to stay competitive and deliver quality care to members. Without a clear approach, opportunities for improvement can be missed—impacting both quality scores and patient outcomes.

FWA Insights: Appropriate billing of intensive outpatient programs

Katie Lewis, RN, BS, CPC — Wed, 15 Oct 2025 13:15:00 GMT

The appropriate billing of intensive outpatient programs (IOPs) for psychiatric services is essential to ensuring the compliance and integrity of healthcare payments. As the demand for mental health and substance use treatment grows, IOPs have become a vital bridge between inpatient care and traditional outpatient therapy. But the complexities of IOP billing in per diem structures can create opportunities for errors and fraud, waste, and abuse (FWA). Understanding how to bill these services properly can help prevent costly mistakes and protect health plans from improper payments.

Case Study: How one plan transformed its Star Ratings strategy

Dani Sutherland — Mon, 13 Oct 2025 19:54:25 GMT

In today’s Medicare Advantage (MA) landscape, maintaining a high Star Rating is more challenging than ever. Centers for Medicare & Medicaid Services (CMS) regulations continue to evolve, quality measures are shifting, and performance thresholds are rising. As a result, MA plans face mounting pressure to adapt or risk falling behind.

The stakes have never been higher. In the 2022 Star Ratings, 74 Medicare Advantage contracts earned a five-star rating. By 2025, that number had dropped dramatically to just seven. This sharp decline highlights a harsh reality. Achieving and sustaining high performance is now the exception, not the norm.

Preparing for 2026: Adapting to new risk adjustment regulations

Katie Sender, MSN, RN, PHN, CRC — Thu, 09 Oct 2025 20:04:51 GMT

Major changes are happening in risk adjustment. The continued scrutiny of health risk assessments (HRAs), the full implementation of the Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) Model Version 28, and other changes are a reflection of how the risk adjustment landscape is constantly evolving. Leaders need to anticipate and adapt strategies to match the changes on the horizon, and plans should be thinking of comprehensive transformation, not just incremental compliance.

MY 2026: Breaking down the latest HEDIS Technical Specifications

Samantha Davis — Tue, 07 Oct 2025 15:26:26 GMT

As health plan leaders prepare for the next cycle of quality reporting, the HEDIS^® Measurement Year (MY) 2026 Technical Specifications represent a significant shift for measure design and reporting requirements. The National Committee for Quality Assurance (NCQA) continues to refine HEDIS measures to better reflect the evolving landscape of healthcare quality assessment, introducing seven new measures for MY 2026 alongside meaningful updates to existing ones. These changes affect risk-adjusted outcomes, electronic clinical data system (ECDS) reporting, and member descriptive information.

Understanding these updates is essential for plans to ensure compliance and maximize performance. We compared the MY 2026 specifications against the materials that NCQA proposed as part of the Public Comment period to help pinpoint adjustments from public feedback and submitted several questions regarding the measures to share additional insights. Here, we offer a structured breakdown of confirmed changes, clarifications, and specific strategies to enable plans to prepare for MY 2026.

Case study: Regional plan exceeds expectations with second-pass COB

Evan Okulanis — Thu, 02 Oct 2025 12:45:00 GMT

Coordination of benefits (COB) is an intricate, time-consuming process for all health plans—sifting through data assets, checking validity, establishing primacy, and more. But having a seasoned partner to cut through complexities for speed, accuracy, and detail can mean significant savings.

That’s why a regional health plan enlisted the help of Cotiviti’s retrospective COB Validation solution and started seeing results fast. Initially using Cotiviti’s prepay Payment Policy Management and Coding Validation solutions, the plan deployed COB Validation in 2024 for commercial and Medicaid lines of business as a second-pass review to find what a first pass might have missed, including more complex issues.

Star Ratings Plan Preview: 4 key recommendations

Thelma Belli — Mon, 29 Sep 2025 14:04:06 GMT

Medicare Advantage (MA) plans are entering a new era of quality reporting. The transition from traditional hybrid HEDIS^® measures to Electronic Clinical Data Systems (ECDS) reporting is accelerating—and many plans may be underestimating its impact on Star Ratings.

Recent Star Ratings data from Plan Preview 2 (PP2) provides a cautionary tale. After the Colorectal Cancer Screening (COL) measure moved to ECDS-only reporting in 2024, its Star Rating cut points dropped across all thresholds by the maximum five points allowed under current guardrails—a clear sign that plan performance suffered when hybrid chart review was removed. As the National Committee for Quality Assurance (NCQA) continues to phase out hybrid measures through 2029, plans must rely solely on ECDS rather than end-of-year chart audits.

Here, as we await publication of the final 2026 Star Ratings, we explain why scores are dropping and offer strategies for MA plans to close out the calendar year with stronger performance.

Busted: The top fraud schemes of Q2 2025

Erin Rutzler, AHFI, CFE, CHC, CPC — Thu, 25 Sep 2025 20:09:00 GMT

As we move through 2025, the pace of fraud, waste, and abuse (FWA) schemes in healthcare show no signs of slowing. This past quarter brought cases involving unlicensed clinics, hospice kickbacks, insider deception, and prescription fraud totaling billions in false claims. Read our breakdown of 10 major healthcare FWA schemes from April through June 2025—and what they reveal about the evolving tactics of bad actors.

Webinar: Deploying AI effectively and responsibly in payment integrity

Brett Arnold — Wed, 17 Sep 2025 18:33:52 GMT

Artificial intelligence (AI) is unlocking numerous possibilities for payers to make costs more sustainable without a negative impact on care quality. According to McKinsey estimates, payers could see net savings of 13–25% in administrative costs and 5–11% in medical costs using currently available AI technology. And indeed, more than 85% of payers surveyed say they’ve either implemented or are exploring proofs of concept for generative AI. But deploying AI comes with significant responsibility: care must be taken to areas of potential risk including data security, accuracy, transparency, privacy, and others.

FWA Insights: Q&A with the SIU

Heather Rickards, MS, AHFI, CFE — Mon, 15 Sep 2025 17:30:53 GMT

While prepay claim editing systems continue to grow more advanced, they can’t prevent every fraud, waste, and abuse (FWA) scheme from slipping through the cracks. That’s why a high-performing special investigations unit (SIU) must be powered by both human expertise and advanced analytics to sift through mountains of data and identify aberrant trends.

Here, we conduct a Q&A with some of Cotiviti’s own credentialed investigators to break down complex questions related to skin grafts and substitutes, agrowing area of FWAcapturing attention nationwide.

7 key steps to build a valuable COB program

Evan Okulanis — Thu, 11 Sep 2025 16:51:37 GMT

Healthcare providers are under significant strain due to escalating costs, heightened post-pandemic demand, and mounting administrative expenses—all of which contribute to undesirable medical loss ratios (MLR). Implementing an effective coordination of benefits (COB) program is a crucial first step to alleviate these pressures: reducing medical expenses, enhancing member satisfaction, and mitigating friction with providers through swift and accurate determination of benefit order, even in intricate cases. An effective COB program also saves health plan resources and reduces provider and member abrasion by decreasing the number of claims that need further review.

eBook: Addressing dental overbilling to improve payment integrity

Steven M. Canfield, D.D.S. — Tue, 09 Sep 2025 16:59:26 GMT

Dental payers face consistent challenges as fraud, waste, and abuse (FWA) continue to escalate costs and threaten the integrity of the system. In 2023, dental expenditures in the United States reached $174 billion, accounting for over 3% of total healthcare spending, according to the American Dental Association. As dental claims continue to grow in both volume and complexity, plans face difficulty identifying improper billing practices amidst the evolving landscape of FWA schemes. Understanding and addressing current dental claim schemes is critical to ensure a fair and transparent environment for payers and providers while protecting member benefits.

Webinar: Prepare for risk adjustment in 2026

Katie Sender, MSN, RN, PHN, CRC — Thu, 04 Sep 2025 13:40:42 GMT

Accuracy has always been critical for risk adjustment coding, and recent policy changes and technology trends will make precision more important than ever in 2026. The new Medicare Advantage RADV auditing strategy announced by the Centers for Medicare & Medicaid Services (CMS) is relying on enhanced technology tools like AI, looking to expedite completion of 2018–2024 audits and begin auditing all Medicare Advantage plans going forward. Advanced analytics will also become key in identifying the risk profiles of member populations and generating actionable insights amid evolving market conditions.

With these and other changes on the horizon, plans should ensure their risk adjustment programs meet the highest standards of accuracy and compliance for the year ahead.

Join me and Senior Product Director Amanda Liu for an on-demand webinar in partnership with RISE as we dive into key regulatory updates and emerging policy trends in 2026. We’ll explore timely topics such as the new CMS Medicare Advantage RADV strategy, increased documentation scrutiny, and updates to Affordable Care Act (ACA) and Medicaid requirements.

Perform Beyond Expectations: Delivering a true solution

Susan Murray — Tue, 02 Sep 2025 16:33:14 GMT

In a disruptive healthcare environment, simply meeting expectations is no longer enough. Between shifting regulations, evolving quality benchmarks, and growing member needs, health plans need more than just a vendor—they need a partner committed to delivering results.

Watch our video from the Cotiviti Client Conference 2025 (CCC25) as Naomi Murphy, senior vice president of data mining and coordination of benefits (COB), joins Marge Ciancetta, product manager for Star Intelligence, to explain how Cotiviti delivers:

Technical plus human expertise: Leveraging expertise from our analysts powered by advanced technology, Cotiviti delivers holistic solutions that empower organizations to make informed decisions and take decisive action across quality improvement, payment accuracy, and more.
Deeper payment integrity reviews: Cotiviti’s unique approach to COB goes beyond surface-level reviews of diagnosis or procedure code to uncover missed coverage and reduce waste.
Industry expertise: Our Star Ratings and payment integrity analysts pull from their deep experience with health plans, enabling them to drive value for our customers.

Webinar: Decoding the HEDIS MY 2026 Tech Specs

Samantha Davis — Thu, 28 Aug 2025 13:10:20 GMT

Following a period of public comment on proposed changes earlier this year, the National Committee for Quality Assurance (NCQA) has published technical specifications for Measurement Year (MY) 2026. Understanding what measures are changing while keeping up with the complexities of evolving HEDIS reporting requirements can be difficult.

For MY 2026, organizations will need to adapt to a new measure format, seven new and two retired measures, the transition of four additional measures into Electronic Clinical Data Systems (ECDS), and several smaller changes. These changes aim to improve data quality and streamline reporting but also require proactive preparation and strategic planning.

Perform Beyond Doubt: Turning uncertainty into informed action

Susan Murray — Tue, 26 Aug 2025 13:24:25 GMT

Health plans face high-stakes decisions daily, often without full visibility into how those decisions will impact provider relationships, operations, or long-term outcomes. All too often, the inability to access critical data at the right moment leads to doubt, making it difficult to reach critical decisions around payment policy and more.

Watch our video from the Cotiviti Client Conference 2025 (CCC25) as Peter Okwera, vice president of analytics, joins Amy Carleton, RN, BSN, senior product director for Clinical Chart Validation, to explain how Cotiviti delivers:

Benchmarking that informs strategy: By leveraging insights across a broad payer network, Cotiviti helps health plans understand what’s working across the market, assess their position, and reduce uncertainty around payment policy updates.
End-to-end support: From chart retrieval to provider education, we help power better decisions across your clinical chart review programs and more instead of taking a piecemeal approach.
Transparency and visibility: Before turning on a new payment policy, health plans can gain confidence in their decision by seeing how it’s impacted other payers and providers in their market.

FWA Insights: Identifying a DME dropshipping scheme

Nikki Brody — Thu, 21 Aug 2025 15:50:26 GMT

Inappropriate billing for durable medical equipment (DME) continues to be among the most prevalent fraud, waste, and abuse (FWA) schemes in healthcare, with the Department of Justice regularly announcing new indictments for DME-related cases that aim to defraud both public and private payers. In one recent case, Cotiviti’s special investigations unit (SIU) identified a licensed DME provider that was not manufacturing its own equipment in many cases, but rather having it dropshipped from a large online retailer directly to the patient, then billing the health plan at a heavily marked-up rate.

Through data analysis, peer comparisons, and documentation requests, Cotiviti’s credentialed investigators were able to identify these inappropriate claims—and put a stop to future problematic billing to prevent more overpayments.

Perform Beyond Hype: Going beyond buzzwords in healthcare

Susan Murray — Tue, 19 Aug 2025 13:27:54 GMT

In a healthcare landscape saturated with promises of transformation through artificial intelligence and automation, payers are focused on what truly delivers results: deep clinical expertise, responsible innovation, and lasting partnerships.

Watch our video from the Cotiviti Client Conference 2025 (CCC25) as Anandhi Periyanan, senior vice president of research and development, joins Jamie Calabrese, M.D., vice president of medical affairs, to discuss how Cotiviti enables health plans to:

Achieve smarter, more responsible innovation: Our integrated SaaS solutions and AI tools are not a replacement for human decision-making—they amplify the work of our expert teams to deliver operational efficiency and high accuracy.
Bridge clinical and financial insights: With a data and analytics ecosystem that maximizes both clinical and financial inputs, Cotiviti helps deliver smarter decisions.
Center clinicians in every solution: From the design of our programs to direct client engagement, physician oversight is embedded throughout the lifecycle of our offerings, ensuring that policies aren’t just effective, but responsible and provider-aligned.

Decoding HEDIS® MY 2024 for success in MY 2025

Jamison Gillitzer — Thu, 14 Aug 2025 16:35:17 GMT

Health plans are under increasing pressure to deliver measurable quality improvement while navigating regulatory shifts, operational complexity, and rising member expectations. While HEDIS^® Measurement Year (MY) 2024 is now in the rearview mirror, the work of quality improvement never stops.

The focus now shifts to off-season projects and preparing for the next cycle. A thorough post-season review—analyzing what worked, identifying delays, and uncovering data gaps—can help plans develop targeted strategies to optimize future performance. By reflecting on challenges and achievements of MY 2024, staying ahead of key changes for the upcoming season, and continuously preparing for digital quality transformation, plans can set themselves up for success in MY 2025 and beyond. Here are a few strategies that can help.

Perform Beyond Silos: Uniting people, programs, and partners across healthcare

Susan Murray — Tue, 12 Aug 2025 14:13:55 GMT

Healthcare’s most persistent challenge isn’t always technology—it’s fragmentation. With departments like quality improvement, risk adjustment, payment integrity, and member engagement often operating independently, it’s easy for health plans to lose alignment on broader goals.

Watch our video from the Cotiviti Client Conference 2025 (CCC25) as I’m joined by Kochelle Denegall, senior director of client and go-to-market effectiveness training, to explain how Cotiviti enables health plans to:

Eliminate internal and external silos: Learn how Cotiviti’s solutions and delivery model bridge program gaps and align efforts across departments.

Turn insight into action: We deliver benchmarking, provider analytics, and dynamic training informed by real-world input from cross-functional teams—helping ensure strategies are relevant, effective, and grounded in shared goals.
Work from a unified North Star: Guided by our Client Pledge, we build solutions based on transparency, partnership, and problem-solving, collaborating closely with clients to achieve better outcomes.

Webinar: Enhancing member engagement and communication

Leah Dewey — Tue, 05 Aug 2025 16:37:05 GMT

Technology enhancements are transforming the healthcare landscape, but with these new improvements, health plans still face the ongoing challenge of effectively engaging with their members—especially amidst the new regulations from the Centers for Medicare & Medicaid Services (CMS). From recent requirements for mid-year benefits notices to the introduction of the Excellent Health Outcomes for All (EHO4all) program and updates impacting dual-eligible Special Needs Plans (D-SNPs), the need for strategic, multi-channel communication has never been greater.

Two key claim trends and their impact on payment integrity

Jonathan Edwards — Wed, 30 Jul 2025 17:18:57 GMT

Healthcare billing practices are constantly evolving, significantly impacting payment integrity for health plans seeking to prevent inappropriate spend and protect their members’ benefits. In particular, emergency department billing and medical drug wastage have become significant contributors to rising expenditures, as evidenced by trends observed directly in claims payment data over the past several years.

Here, we examine these trends in detail and offer strategies for payers to protect against inappropriate billing, helping to ensure claims are paid appropriately the first time and reducing the need to pursue overpayment recovery.

FWA Insights: Uncovering improper billing in urine drug screens

Heather Rickards, MS, AHFI, CFE — Thu, 17 Jul 2025 14:34:54 GMT

Improper billing practices and schemes related to urine drug screens (UDS) are common, requiring investigative resources to detect potential fraud, waste, and abuse (FWA). Though the Centers for Medicare & Medicaid Services (CMS) regulates human lab samples through strict guidelines outlined in the required Clinical Laboratory Improvements Amendments (CLIA) certification, some laboratories and testing facilities may lack up-to-date certifications, posing a risk to members and payers alike.

As demonstrated in one recent investigation conducted by Cotiviti’s special investigations unit (SIU), with meticulous medical review and data mining, health plans can safeguard member care and help reduce improper billing.

Unlocking business value through interoperability: 3 key strategies

Katie Devlin, DHSc, MS, CPHIMS — Tue, 15 Jul 2025 17:12:31 GMT

As healthcare organizations navigate the evolving digital landscape, interoperability has become more than a regulatory requirement—it’s a strategic imperative. Health plans that effectively leverage interoperability to drive efficiency, improve data quality, and deliver measurable business value will be best positioned for success across programs that rely on robust digital data exchange.

Below are three essential strategies—highlighted in our recent RISE webinar—to help payers maximize the value of their interoperability investments as key industry deadlines draw closer.

Case study: Prepay COB boosts payment integrity results for large national payer

Evan Okulanis — Thu, 10 Jul 2025 18:58:49 GMT

One of the most critical aspects of using analytics in coordination of benefits (COB) is the ability to pause and review claims before payment. This proactive approach involves temporarily holding claims for a detailed review to verify their accuracy and ensure correct assignment of payment responsibility. By intervening at the right time, health plans can prevent overpayments, reduce future erroneous payments, and confirm that primary payment responsibility is correctly assigned, all while lowering provider abrasion.

After partnering with Cotiviti for more than 20 years to build a payment accuracy program—including prepay claims editing, postpay data mining, and DRG review auditing—a large national payer with millions of Medicaid, Medicare, and commercial members added Cotiviti’s prepay pause-and-review process to its retrospective COB program in 2020.