Cotiviti
Healthcare analytics and payment accuracy company with AI-powered claims review, risk adjustment, and payment integrity.
What it does
Cotiviti is a healthcare analytics and payment accuracy company serving health insurance payers - providing AI-driven solutions for payment integrity (identifying overpayments and fraud before and after claims payment), risk adjustment (ensuring accurate member risk scores for ACA and Medicare Advantage programs), quality improvement analytics, and consumer analytics. AI capabilities include machine learning claims anomaly detection that identifies billing irregularities, upcoding, and unbundling patterns across claims data, AI-powered risk adjustment analytics that ensure all member diagnoses are appropriately captured and coded for accurate premium revenue, predictive quality analytics that identify gaps in preventive care and chronic disease management for HEDIS measure improvement, and consumer analytics that segment member populations for targeted outreach.
Why AI-ENHANCED
Cotiviti is an established healthcare payment accuracy company that has meaningfully integrated machine learning claims anomaly detection, AI risk adjustment analytics, and predictive quality analytics into a mature payer payment integrity and analytics product.
Best for
Health insurance plans, Medicare Advantage organizations, and Medicaid managed care companies use Cotiviti for payment accuracy and risk adjustment - AI identifying overpayments that reduce medical loss ratio and ensuring accurate risk scores that optimize premium revenue.
Limitations
Cotiviti is purpose-built for health insurance payers managing claims payment accuracy and risk adjustment — provider-side revenue cycle, pharmacy benefit managers, and non-payer organizations have limited applicable use cases.
Medicare Advantage and ACA risk adjustment involves complex CMS regulations — Cotiviti's analytics amplify expert compliance teams rather than eliminating the regulatory expertise requirement.
Cotiviti's services are priced and designed for health plans with significant membership — smaller health plans rarely have the claims volume where payment integrity and risk adjustment analytics generate sufficient return.
Alternatives by segment
| If you need… | Consider instead |
|---|---|
| Claims processing platform | Change Healthcare |
| Payment integrity analytics | Optum |
| Healthcare payer analytics | Health Catalyst |
Cotiviti services priced as a percentage of identified savings or overpayments recovered, plus subscription fees. Not published. Enterprise health plan contracts run millions annually depending on membership and services scope.
