Working with procurement officials at the federal, state, and local level to audit third-party supplier agreements in order to protect taxpayer value. Cotiviti's experienced contract compliance audit team completes hundreds of audits per year for government clients, deploying a mix of proprietary technology and highly experienced teams to review the terms, conditions, and intent of suppliers' contracts against goods and services actually delivered. Committing to a robust audit of expenses and supplier contracts provides insight into current spending, serves as a supplier performance scorecard, and protects the public against fraud, waste, and abuse. Established procedures and policies must be followed to ensure a fair and transparent contracting process, and Cotiviti's supplier relationship network helps navigate the negotiation and settlement process for fair and favorable outcomes.

Curtailing third-party overpayments to realize negotiated contract value for health plans, life sciences companies, hospital systems, and group purchasing organizations (GPOs) that spend billions of dollars outside of medical treatment. Cotiviti performs contract compliance of third-party vendor expense agreements and accounts payable audits in the healthcare sector to identify financial leakage across indirect spend categories. Health plans can realize additional savings by applying the same level of rigor to non-medical third-party vendor contracts as they do to medical claims. Pharmaceutical and biotechnology companies invest heavily in research and development and CRO relationships, while hospital system expenditures span facilities, waste management, supplies, and real estate—all areas where overpayment for goods and services can occur.

Solving unique challenges and delivering domain-specific insights for grocery chains and pharmacy retailers across North America. With an average partnership length of more than 16 years per client, Cotiviti's Grocery leadership team specializes in procurement and discount negotiations, new item offerings, and promotional/volume rebates—protecting margins in a sector experiencing rapidly changing conditions. The evolving pharmaceutical supply chain and wholesaler contract agreements create substantial recovery and future savings opportunities. Cotiviti partners with national pharmacy chains and grocery clients to identify claims in price protection, price increase, and cost overcharge, while also addressing wholesaler contracting inconsistencies and Group Purchasing (GPO) agreement issues.

Audit and recovery services tailored to the world's largest mass merchant retailers, where transaction volumes run into the billions and e-commerce channels are rapidly expanding alongside brick-and-mortar operations. Cotiviti operates as the primary pass audit for 75% of its mass merchant clients, consistently beating recovery budget expectations through continuous process improvement and collaboration with internal audit teams. Engineering teams partner directly with field auditors to build custom tool enhancements and data integrations—including email keyword mining—that drive above-average audit results. With an average client relationship exceeding 10 years, the focus on innovation and transparency helps mass merchants maintain positive supplier relationships while maximizing recoveries.

Creating ongoing efficiencies and expanding recovery opportunities for specialty retailers including home improvement (DIY), home office, sporting goods, pet supplies, health and wellness, and next-generation omnichannel retailers. A flexible approach, customized to meet each client's structured and unstructured data needs, is driven by metrics-driven management and a unified methodology across clients. Cotiviti serves as the primary audit recovery firm for leading home improvement retailers and leverages email data mining technology and keyword matching to identify vendor communication breakdowns. The Specialty Retail team's focus on data quality—addressing missing, incorrect, and incomplete data—allows deeper integration of additional data elements to maximize audit value.

Delivers solutions across the full claim payment lifecycle—from payment policy management and coding validation to clinical chart review, fraud/waste/abuse detection, and contract compliance—to unlock medical and administrative cost savings for healthcare payers. Using data mining and advanced analytics, investigators identify outlier billing patterns and recover overpayments while protecting payment integrity against emerging risks. The service achieves 99.90% six sigma accuracy rates and is validated across 100+ payer clients. Core capabilities include Payment Policy Management, Coding Validation, Dental Claim Accuracy, Clinical Chart Validation, Contract Compliance, COB Validation, FWA Pattern Review, and Claim Pattern Review. By combining forensic investigation techniques with compliance validation, the offering ensures claims are processed correctly while simultaneously detecting and preventing fraud, waste, and abuse patterns across the entire payment lifecycle.

Delivers procure-to-pay audit and recovery solutions—including recovery auditing, contract compliance, and Zero Hour Alerts—to help the world's largest retailers eliminate overpayments and financial leakage across their supplier networks. Serving 30 of the world's largest retailers and Fortune 1000 companies with an average client relationship of 16.5 years, the offering combines systematic procure-to-pay auditing with contract management and real-time exception monitoring to identify and recover overpayments. Core capabilities include Recovery Audit (identifying and recovering duplicate, erroneous, and non-compliant payments), Contract Compliance validation (ensuring supplier invoices align with negotiated terms and pricing), Procure-to-Pay auditing (validating requisition-to-payment processes), and Zero Hour Alerts (real-time identification of billing anomalies and exceptions). The service leverages data analytics and forensic investigation techniques to detect patterns of financial leakage and enable systematic recovery across complex, multi-location retail and supplier environments.

Cotiviti's Health Enablement suite empowers health plans, government agencies, and healthcare providers to optimize clinical and financial performance across risk adjustment, quality improvement, and member engagement. The suite combines advanced analytics, AI, NLP, and deep subject-matter expertise to deliver accurate member risk coding, HEDIS and Star Ratings optimization, and targeted multi-channel member engagement. Core solution areas include Risk Adjustment (retrospective and prospective risk scoring, medical record retrieval and coding, encounter management, and CMS compliance), Quality and Stars (HEDIS measure certification, Star Intelligence, Quality Intelligence, and Medical Record Abstraction — backed by 25 consecutive years of NCQA HEDIS certification), and Engagement (personalized omnichannel member outreach via Eliza and Engagement Hub to drive preventive care, medication adherence, and care gap closure). Together these capabilities enable health plans to improve revenue accuracy, quality performance, and member health outcomes across Commercial, Medicare Advantage, and Medicaid lines of business.

A gold-standard risk adjustment and predictive modeling platform that analyzes clinical and financial data to generate individual member risk scores, validated by the Society of Actuaries. The platform combines actuarial science with advanced data analytics to compute HCC-based and condition-based risk scores that drive medical loss ratio (MLR) calculation, capitation setting, and member health stratification for health plans. DxCG Intelligence enables population risk segmentation, predictive modeling for future healthcare costs, and benchmarking against industry standards. The platform integrates claims data, medical record coding outputs, and demographic information to deliver member-level risk profiles that support financial planning, quality improvement initiatives, and targeted care management programs across Medicare Advantage, commercial, and Medicaid populations.

A member engagement SaaS platform (formerly Eliza® Member Engagement) that uses data-driven outreach to connect health plan members with the interventions and programs they need. The platform leverages predictive analytics and member segmentation to identify at-risk populations and deliver timely, personalized communications that drive member engagement with preventive care, chronic disease management, and plan-sponsored programs. Eliza enables health plans to execute targeted outreach campaigns across digital channels, track member engagement and program enrollment, measure health and financial outcomes from engagement initiatives, and continuously refine targeting and messaging based on response data. The platform supports integration with health plan systems to enable closed-loop engagement workflows and real-time visibility into member program participation and clinical outcomes.

A multi-channel member engagement platform that enables health plans to deliver targeted, personalized outreach to drive member action and improve health outcomes. The platform integrates member data, segmentation, and campaign orchestration capabilities to support coordinated communication across email, SMS, web, IVR, and other channels. Health plans can design, execute, and measure the impact of member engagement campaigns focused on preventive care, medication adherence, care coordination, and plan-specific objectives. Engagement Hub enables sophisticated member segmentation based on clinical risk, demographic characteristics, engagement history, and behavioral patterns. The platform supports personalized message creation, multi-channel delivery coordination, real-time response tracking, and outcome measurement to continuously optimize engagement effectiveness and drive measurable improvements in health plan performance metrics including Star Ratings, HEDIS measures, and member satisfaction scores.

A SaaS platform that enables health plans to track, manage, and optimize HEDIS® quality measures, Star Ratings, pay-for-performance, and custom quality programs in a single solution. The platform aggregates clinical, claims, and operational data to provide real-time visibility into quality metric performance, identifies gaps at member and provider levels, and enables drill-down analysis to support targeted quality improvement initiatives. Quality Intelligence delivers dashboards, reporting, and analytics capabilities that support compliance monitoring against NCQA HEDIS standards and CMS Star Rating requirements. Health plans use the platform to track individual quality measures in real-time, forecast Star Rating performance, identify at-risk members and providers, and measure the impact of quality improvement programs and interventions on overall plan and member-level outcomes.

A platform supporting health plans in managing CMS Five-Star Quality Rating System performance for Medicare Advantage Part C and Part D programs. The platform provides detailed visibility into individual Star measure performance, tracks progress toward targets, forecasts year-end Star Ratings, and identifies opportunities for improvement across clinical quality, member satisfaction, and medication adherence measures. Star Intelligence integrates CMS Star measure logic with claims, enrollment, and quality data to enable real-time performance tracking and scenario modeling. Health plans use the platform to monitor compliance with CMS requirements, identify high-impact improvement opportunities, measure the effectiveness of targeted interventions, and support strategic decision-making around plan design and member outreach to optimize Five-Star Rating performance.