Cotiviti

The infrastructure layer powering healthcare

[Christina Farr @chrissyfarr]

New Lifers this week: Ric Sinclair, CEO of Cotiviti, makes the case that healthcare's problem isn't data or technology. It's coordination.

TIMESTAMPS
(00:00) Lead In
(00:32) Intro
(00:59) Drumming to leadership
(04:00) From music to health tech
(08:35) Waystar product lessons
(11:00) Waste and infrastructure gaps
(12:29) AI could raise costs
(15:48) Cotiviti CEO origin story
(21:01) Ending the finger pointing
(27:41) Execution and convening stakeholders
(30:16) Gold carding teaser
(30:48) VIP prior auth idea
(32:09) Coordination not data
(33:42) Plant the orchard
(34:58) AI as services model
(37:21) Humans in the loop
(40:39) Reskilling and job shifts
(42:57) AI literacy and adoption
(46:02) Polite to the bots
(47:34) Smaller teams bigger output
(50:51) Creativity still human
(55:17) Cotiviti values framework
(57:35) Legacy and less waste
(58:48) Can stakeholders share pain?
(01:00:58) Wrap

[Cotiviti @Cotiviti]

Thank you, @NCQA! We are proud to partner with you to advance digital quality.

[NCQA @NCQA]

A big congratulations to @Cotiviti on completing NCQA's HEDIS Digital Certification for all measures for MY 2025!

Learn how Cotiviti and other organizations are leading the charge in Digital Quality Measurement: https://t.co/YYcG3zWMLy

[Cotiviti @Cotiviti]

Medication adherence and risk capture are more connected than many MA plans realize. Members non-adherent to chronic condition treatments are often the same individuals whose conditions may be under-documented from a risk perspective.

via @RISEhlth: https://t.co/gFMQQrPhTn

[Cotiviti @Cotiviti]

Risk-adjusted medication adherence replaces traditional adherence in MY 2026 and increases to a weight of three in MY 2027, introducing greater score dispersion and increasing both upside opportunity and downside risk across contracts.

Read more: https://t.co/iVzgXNgH5d

[Cotiviti @Cotiviti]

Many health plans still rely heavily on post-pay recovery.

Cotiviti's new eBook explores why rethinking payment integrity throughout the full claim lifecycle yields stronger, more sustainable results. https://t.co/Cwve3J5FtA

[Cotiviti @Cotiviti]

Cotiviti has now validated all digital #HEDIS measures for MY 2025, helping health plans manage both traditional and digital reporting from a single platform.

Watch and learn how Cotiviti and @NCQA are helping accelerate the future of digital quality measurement.

[Cotiviti @Cotiviti]

Clearinghouses and vendor-specific gateways introduce additional translation layers and operational constraints, increasing complexity and reducing transparency in payer-provider integration.

Cotiviti's Maxim Abramsky explains via @hcittoday: https://t.co/Vs5g969tbJ

[Cotiviti @Cotiviti]

New APCM behavioral health add-on codes create billing flexibility for providers, but also introduce heightened risk of standalone billing, unbundling, and incomplete care-team documentation.

Read the key vulnerabilities health plans should monitor: https://t.co/Dx5dXtSfEA

[Cotiviti @Cotiviti]

A large national health plan achieved a 45% increase in DRG program value in its first year after adding Cotiviti's prepay Clinical Chart Validation solution to its existing postpay program.

Read the case study: https://t.co/D3WpZJRoCz

[Cotiviti @Cotiviti]

43% of health payers rank managing specialty drug costs as their top priority, according to PSG's Trends in Specialty Drug Benefits report. Last year, 76% of novel FDA-approved drugs were specialty drugs.

Read more via @FierceHealth: https://t.co/PFURoB0jdE

[Cotiviti @Cotiviti]

Sepsis accounts for approximately 14% of inpatient costs across all lines of business.

Cotiviti data suggest the opportunity for improvement lies less in reducing admissions and more in supporting accurate clinical documentation and coding.

Learn more: https://t.co/YYA6RHGBNu

[Cotiviti @Cotiviti]

A mid-sized health plan achieved 1.6% annual medical cost savings by reducing improper payments through Cotiviti's prepay editing solutions.

Read the case study: https://t.co/hY2zufextG

[John Lynn @techguy]

Addressing Interoperability and Data Standardization Challenges that Continue to Hinder Payer-Provider Integration #HITsm @tendo_systems @Cotiviti @Navina_ai @documocloud @KeenStack @WebPT 
https://t.co/cYeGNBRN1r

[Cotiviti @Cotiviti]

42% of DRG claims audited for one large national health plan resulted in an overpayment finding, underscoring the value of precise, AI-enabled chart selection focused on claims with the highest probability of an error.

Read the full case study: https://t.co/D3WpZJRoCz

[Cotiviti @Cotiviti]

RADV audits focus on evidence rather than intent. Unsupported diagnoses are routinely flagged, making defensible documentation a critical priority for risk adjustment programs.

Learn how to identify and respond: https://t.co/mlqymLQMUP

[Cotiviti @Cotiviti]

Star Ratings structural changes in the 2027 Final Rule reduce the number of contributing measures, amplifying performance variability and leaving plans with less margin for error.

Cotiviti's Branka Sustic reviews what it means for MA plans: https://t.co/gFMQQrPhTn via @RISEhlth

[Cotiviti @Cotiviti]

Depending on occupation, 3 in 4 employees are offered health insurance, and 65% of those offered enroll in the benefit, per a recent @KFF brief on employer health coverage and lower-wage workers.

Read more: https://t.co/bJYnm5sbc9

[Cotiviti @Cotiviti]

The 2027 CMS Final Rule confirms the Star Ratings program is shifting decisively toward outcomes. As operational measures are retired, remaining categories carry greater weight, and plans have less margin for error.

Cotiviti's Marge Ciancetta reviews: https://t.co/a3GPaNWzP2

[Cotiviti @Cotiviti]

CMS and the FDA introduced the RAPID coverage pathway for breakthrough medical devices, with payment available as early as 2 months after market authorization, compared with the current payment timeline of approximately 1 year or more. via @HC_Finance: https://t.co/Q1w8bz8tiw

[Cotiviti @Cotiviti]

Correct coding is often viewed as an administrative burden. In practice, it is foundational to payment integrity, data quality, risk adjustment, Star Ratings reporting, and patient outcomes.

Cotiviti's Brad Terry, M.D., breaks down why in our latest blog: https://t.co/0mouejylmo