Cotiviti

Step 1: Analyze historical claims data to identify patterns of improper billing.

Step 2: Implement automated claim review processes to flag potentially non-compliant claims.

Step 3: Conduct medical record reviews to validate the accuracy of billed services.

Step 4: Provide education and training to providers on proper coding and billing practices.

Step 1: Identify members who are not meeting HEDIS measure requirements.

Step 2: Implement targeted outreach programs to encourage members to receive necessary screenings and vaccinations.

Step 3: Collect and submit complete and accurate data to NCQA.

Step 4: Monitor HEDIS performance and make adjustments to strategies as needed.

Step 1: Analyze claims data and medical records to identify undocumented conditions.

Step 2: Conduct retrospective chart reviews to validate diagnoses and capture additional risk-adjustable codes.

Step 3: Submit accurate and complete risk adjustment data to CMS.

Step 4: Monitor risk adjustment performance and identify areas for improvement.

Step 1: Segment members based on their health risks and preferences.

Step 2: Develop personalized messaging and outreach strategies.

Step 3: Offer a variety of engagement channels, such as email, text, and phone.

Step 4: Track engagement rates and measure the impact on health outcomes.

Step 1: Analyze pharmacy claims data to identify suspicious patterns, such as high-volume prescriptions or unusual billing codes.

Step 2: Conduct on-site audits of pharmacies to verify the accuracy of billing records.

Step 3: Investigate potential fraud cases and take appropriate enforcement actions.

Step 4: Implement preventative measures to deter future fraudulent activity.