Payment Integrity Program

Claims and billing is becoming increasingly complex, requiring new levels of checks and balances. National statistics attribute 3-7% of health care spending to the result of wrongful charges—both accidental and intentional.

Cotiviti is recognized in the industry as the leading health care analytics expert. One of their core strengths is payment accuracy. Among their clientele are 21 of the nation’s top 25 health care payers.

Cotiviti’s sophisticated technology examines billions of clinical and financial data points to which they apply health care logic and subject matter expertise to prevent and recover improperly paid claims. The cost of the enhanced analytic services is retained from the additional savings realized.

Other Blue Cross Blue Shield plans using Cotiviti for enhanced claims analysis have reported additional savings of 1-2% from their annual claims spend. We’re expecting similar numbers once the program is fully implemented.

In-state retrospectively audited claims (post-pay) will be applied monthly as early as Q3 '22 if you are a fully insured client, and Q1 '23 if you are a self-funded client.

In-state prospectively audited claims (pre-pay) will be applied weekly as early as Q4 '22 if you are a fully insured client, and Q1 '23 if you are a self-funded client.

BCBSND’s current claims review process saves North Dakota employers millions of dollars. However, deeper savings require an expanded strategy, which includes advanced data analytics-based programs. We receive that level of analysis through a partnership with Cotiviti and other Blues plans.

If you are a Self-funded client, retaining a portion to cover program costs is the industry standard for providing enhanced payment integrity services and allows us to not increase administrative fees. And it’s a necessary investment to protect our clients and members from inappropriate billing practices.

If you are a self-funded client, your invoice will look different. Since a portion of the savings found through enhanced claims analysis are retained to cover administrative costs, your billing will look different.

Once per month, your weekly invoice summary will be adjusted to reflect savings for the previous month’s enhanced program analytics.

Detailed reporting will also be available upon request.

The brochure above has more detailed information about the change. Additionally, your account representative is available to address any questions or concerns.