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Cotiviti: The Company That Can Undo a Claim After It Was Already Paid
What Cotiviti is, how they work, and what to do if they come after your care. A procedure that seemed covered can become your problem â€” months later.

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Cotiviti Â· Payment Audits
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What Cotiviti Does

Cotiviti is a healthcare "payment integrity" company. They review claims on behalf of insurers â€” looking for reasons to reduce or reverse payments. They work with health plans covering what they describe as the majority of U.S. healthcare consumers. Plans that have confirmed using Cotiviti include Blue Cross Blue Shield plans in multiple states, Aetna, Geisinger Health Plan, Meridian Medicaid (Illinois), and 1199SEIU Benefit Funds.

Cotiviti does two types of reviews: prepay (flagging a claim before your insurer pays, which can delay or prevent payment) and postpay audit (reviewing a claim after payment has already been made and seeking to recover money for the insurer).

Providers have reported receiving batches of 90 or more denial letters from Cotiviti for patient diagnoses that were never supported by a review of the actual medical record. The denials arrived by regular mail with a 30-day response window, for encounters no human at Cotiviti had actually reviewed.

The Machine Learning Problem

Cotiviti uses a process called "cross-claim clinical review" which uses machine learning to issue denial determinations without first requesting your medical records. The algorithm compares your inpatient stay against your claims history looking for what they consider mismatches in diagnoses or procedures.

The practical result: a machine flags your chart as suspicious, a denial goes out, and your provider is on a deadline to respond â€” regardless of whether anyone looked at your actual records. If the provider does not respond in time, the denial stands. Financial pressure eventually flows to patients.

How This Affects Patients

Your provider receives a clawback demand and sends you a bill for care you thought was covered

A claim is flagged prepay and your provider is told payment will not be released, delaying your care or prompting them to ask you to pay upfront

A diagnosis code is removed from your record because the algorithm did not find prior history of that diagnosis â€” even if it was a new or acute condition. Your diagnosis codes follow you and gaps can affect future care approvals.

What You Can Do

STEP 01

If you receive an unexpected bill after care was completed

Ask your provider for the Explanation of Benefits from your insurer. Request the specific denial reason in writing. Find out whether a third-party auditor like Cotiviti was involved. You have the right to know who made the determination and on what basis.

STEP 02

If a diagnosis code was changed or removed

Ask your provider whether they received a Cotiviti audit determination that altered the claim. If so, your provider can appeal to Cotiviti directly and submit the actual medical records. Request a copy of your medical records to verify what is documented.

STEP 03

File a complaint with your state insurance commissioner

If you believe a bill resulted from an improper audit, file a complaint with your state insurance commissioner. If your plan is a Medicaid managed care plan, file with your state Medicaid agency as well. Cotiviti operates under contract with your insurer â€” the insurer is ultimately accountable for how audits are conducted.

The appeal process is available to providers and, in many cases, to members. If a claim was denied after a Cotiviti audit, your provider can appeal within the timeframe stated in the determination letter. Encourage your provider to do so and ask to be kept informed of the outcome.

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