Case Study: Major Health Plan in North Carolina achieves over 50% value-based care adoption and smarter provider specialty tiering with Cotiviti

Accelerating value-driven care A comprehensive approach to provider specialty tiering

Major Health Plan in North Carolina, which serves nearly 4 million members, needed a transparent, fair way to steer patients to higher-value specialty providers while responding to rising consumer healthcare costs. The plan faced challenges defining specialty-specific quality and cost standards, communicating benchmarks to providers, and ensuring buy-in as it moved toward value-based care; to address the network-value dimension it partnered with Cotiviti and adopted Cotiviti’s Network Intelligence Risk-Readiness provider scoring (Network Intelligence).

Cotiviti supplied Network Intelligence benchmarks and a provider scoring system that rolls up visit, procedure, pharmacy, and referral measures into a network value/efficiency score, which the plan combined with quality and cost metrics to assign practice-level tiers and engage specialty advisory groups. The Cotiviti-enabled tiering program expanded across multiple specialties, increased provider engagement, and helped the plan identify higher-quality, lower-cost providers—by December 2020 the plan had achieved more than 50% membership in value-based care arrangements—while laying groundwork for broader value-based payment initiatives.