When a health plan is deciding whether to pay a claim, there’s no shortage of information to consider and reviews that must be performed, including medical coding and documentation. And perhaps the most challenging question to answer is this: is the information on the claim clinically appropriate?

On episode 18 of “From the Trenches” podcast, we speak with Marla Wilson, Cotiviti vice president of clinical and coding operations, and Ken Sabulsky, vice president of audit operations. Listen as they dive into how Cotiviti reviews member claim history and medical charts to ensure clinical appropriateness.

Payment accuracy programs are critical to delivering value to health plan members. Some plans excel at recovery management while others struggle—and the difference in financial results is significant. But regardless of size, any health plan can improve its recovery results by pulling a few key levers. Cotiviti's Chris Mastro, vice president of operations, once again joins Jeremy Bamford, senior product director for payment accuracy, to look at what drives success in recovering claim overpayments.

For health plans, managing payment recovery is very challenging and hard to accomplish without negatively impacting their net promoter scores. And this proves especially difficult when using collection agencies that are not experts in claims payment and the plan’s individual overpayment concepts. On the latest episode of our “From the Trenches” podcast, Cotiviti’s Chris Mastro, vice president of operations, joins Jeremy Bamford, senior product director for payment accuracy, to examine the keys to successful claim overpayment recovery.

Although the cost of inpatient hospital stays continues to rise, health plans are finding that their inpatient claim auditing programs are returning less value. They’re also facing challenges such as provider abrasion resulting from requesting too many medical charts to validate those claims, which makes it more difficult to successfully retrieve medical records. We talk with Cotiviti product director Jena Reilly about how health plans be more selective and focus on pursuing medical records that will actually return value back to the plan.

As they look to tame their data and turn it into actionable insights, many payers are significantly ramping up their data analytics strategy by building a data lake, housing both structured and unstructured data. Serving 1.5 million members, Excellus BlueCross BlueShield of New York is making significant progress on its own data lake journey. We speak with Tom Morley, manager of analytics and data strategy for Excellus.

The longstanding barriers to data sharing between healthcare organizations have been breaking down over the past decade, removing a major obstacle to partnerships between payers and providers. But major challenges remain, as data management only continues to grow in complexity and healthcare organizations try to make sense of a flood of information. Cotiviti chief analytics officer David Costello joins the podcast to discuss the best framework for better data management in healthcare.

Healthcare organizations must constantly improve their technologies and processes to stay one step ahead of healthcare fraud. So, what does the leading national organization focused on the fight against healthcare fraud see on the horizon in this ongoing battle? On the latest episode of our “From the Trenches” podcast, we sit down with Louis Saccoccio, CEO of the National Healthcare Anti-Fraud Association (NHCAA) at the organization’s 2018 Annual Training Conference.

When a health plan denies a claim, the provider wants to know why it was denied. Sometimes, the answer is that a modifier appears to have been used inappropriately, which Cotiviti detects using a process we call clinical validation. And as it turns out, clinical validation doesn’t just lead to better outcomes for the payer, but also the members and providers that it serves. On the latest episode of Cotiviti's “From the Trenches” podcast, we talk with John Neumann, registered nurse and clinical consultant for Cotiviti’s Payment Accuracy solutions.

Compliance is becoming an increasingly difficult challenge for Medicare Advantage plans, especially when it comes to their risk adjustment programs. When CMS selects plans for a risk adjustment data validation (RADV) audit, they need to have a high degree of certainty that their diagnoses submitted for reimbursement are valid. So, what’s the solution? We look at the benefits of coding claim validation with Lesley Brown, Cotiviti vice president of Risk Adjustment.

You’ve submitted your final data to NCQA and CMS, marking the end of the HEDIS® 2018 marathon. Now it’s on to the next challenge: Star Ratings performance. In the latest episode of Cotiviti's “From the Trenches” podcast, we wrap up this year’s HEDIS season, discuss the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System, and introduce Star Navigator, a new solution to enable Medicare Advantage plans to optimize their Star Ratings.