Cotiviti
Cotiviti is a PE-backed (KKR/Veritas) healthcare analytics company that provides AI-enabled payment accuracy, risk adjustment, HEDIS quality measurement, member engagement, and — post-Edifecs — interoperability solutions to 200+ U.S. healthcare payers, CMS, and Fortune 1000 retailers.
- Company typePrivate
- Founded1979
- HeadquartersAtlanta, United States
- Headcount5,001–10,000
- GTM typeB2B
- OfferingSoftware
What Cotiviti does
Cotiviti is a privately held, KKR- and Veritas Capital-backed healthcare analytics and payment integrity company founded in 1979 and headquartered in South Jordan, Utah. It sells AI-enabled payment accuracy, risk adjustment, quality measurement (HEDIS), and member engagement (Eliza) solutions to U.S. healthcare payers, government programs (CMS Recovery Audit Contractor contracts for Medicare Regions 3, 4, and 5), and employers, brokers, and TPAs. The company also operates a separate Cotiviti Retail business unit providing recovery audits, contract compliance, and preventive payment accuracy services (including Zero Hour Alerts) to Fortune 1000 retailers and enterprise clients.
Cotiviti's platform spans the full payment lifecycle — connecting prepay and postpay claim review with clinical chart validation, coding, FWA pattern detection, and contract compliance — and delivers documented outcomes including a 45% increase in program value, 99% appeal sustainability, and $124+ per-member-per-year reduction in improper payments. The March 2025 acquisition of Edifecs for over $3 billion added healthcare data interoperability cloud capabilities (serving nearly 300 million people in the U.S. healthcare market) and CMS Payer Interoperability leadership, anchoring the combined platform for value-based care adoption.
The business model is enterprise B2B with subscription and usage-based pricing for software and analytics, professional services for CMS RAC contracts, and transaction-based/recovery-based pricing for retail audit work. Cotiviti serves more than 200 healthcare payers (including the top 25 U.S. health plans), has long-retention retail client rosters (16+ year average grocery/pharmacy tenure), and employs 5,001–10,000 staff globally with delivery operations shifting from Nepal to India. The company is led by incoming CEO Ric Sinclair (effective March 2026) following a decade under Dr. Emad Rizk.
Cotiviti firmographics
Firmographics- Name
- Cotiviti
- Legal name
- Cotiviti, Inc.
- Website
- https://cotiviti.com
- Company type
- Private
- Founded year
- 1979
- Operating status
- Operating
- Headcount range
- 5,001–10,000 employees
- Short description
- Cotiviti is a PE-backed (KKR/Veritas) healthcare analytics company that provides AI-enabled payment accuracy, risk adjustment, HEDIS quality measurement, member engagement, and — post-Edifecs — interoperability solutions to 200+ U.S. healthcare payers, CMS, and Fortune 1000 retailers.
- Ownership category
- akta.pro rank
Cotiviti industry classification
Industry- Product category
- Healthcare Payment Integrity Analytics
- NAICS
- Computing Infrastructure Providers, Data Processing, Web Hosting, and Related Services (518)
- SIC
- Services-Prepackaged Software (7372), Accident & Health Insurance (6321)
- akta.pro primary industry
- Revenue Cycle, Coding & Telehealth Compliance Platforms (for provider orgs) (HLALABAM)
- akta.pro secondary industry
- Quality, Peer Review & Compliance Tools (MQSA/ACR/QA) (HLACALAL)
Keywords
Where Cotiviti is headquartered
LocationHeadquarters
- HQ city
- Atlanta
- HQ country
- United States
- HQ region
- North America
Offices4 records
Markets served
Cotiviti business model
Business model- GTM type
- B2B
- Offering type
- Software
- Cost components
- Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure
Revenue model
- Healthcare Software and Analytics Services: Subscription-based and usage-based pricing for healthcare payment accuracy, risk adjustment, quality measurement, and engagement solutions sold to healthcare payers, government, and providers.
- CMS Recovery Audit Contractor Services: Government contracts for Medicare Regions 3, 4, and 5 RAC audits including DME-related audits, representing recurring government revenue.
- Retail Audit Services: Recovery audit, contract compliance, and payment accuracy services for retail sector clients including Fortune 1000 companies.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Subscription | Annual | Enterprise healthcare payer solutions |
| Transaction based/ take rate | Pay-as-you-go | Retail audit services |
Go-to-market motion3 records
Distribution channels4 records
Marketing channels7 records
Cotiviti product offering
Product offeringCore offering
Cotiviti is a healthcare analytics company that provides payment accuracy, risk adjustment, quality measurement, and member engagement solutions to healthcare payers, government programs, and providers. Through its 2025 acquisition of Edifecs, it also delivers healthcare data interoperability cloud solutions. A separate Cotiviti Retail unit supplies recovery audit, contract compliance, and payment accuracy services to retail and enterprise clients.
Product overview
Cotiviti is a healthcare software and data analytics company offering a platform-plus-modules architecture. The core healthcare platform provides four integrated solution areas: Payment Accuracy (covering claim accuracy, payment policy, coding validation, clinical chart review, data mining, contract compliance, COB validation, and FWA detection), Risk Adjustment (retrospective and prospective solutions including suspect analytics, medical record retrieval/coding, concurrent review, and DxCG Intelligence), Quality and Stars (HEDIS measure optimization and Star Ratings improvement), and Engagement (Eliza member engagement platform and Engagement Hub for multi-channel outreach). Through the 2025 acquisition of Edifecs, Cotiviti expanded into healthcare interoperability with cloud-based claims submission and eligibility solutions. The company also operates Cotiviti Retail, a separate business unit providing recovery audit, contract compliance, and Zero Hour Alerts for supplier payment accuracy across retail and enterprise industries.
Differentiator
Problem solved
Functional benefit
Brands
- Eliza: Member engagement and outreach solution for health plans to drive member action and improve health outcomes
- Cotiviti Retail
- Cotiviti GOV Services
Products and services
- Payment Accuracy End-to-end healthcare payment integrity solution suite covering claim accuracy, payment policy management, coding validation, clinical chart validation, data mining, contract compliance, COB validation, and fraud/waste/abuse pattern review across the prepay and postpay continuum. Sold to healthcare payers and government programs.
- Risk Adjustment Complete retrospective and prospective risk adjustment solution set including suspect analytics, medical record retrieval and coding, second-level review, retrospective review, member suspecting, pre-visit prep, post-visit review, concurrent risk adjustment, encounter management, and DxCG Intelligence risk modeling. Target customers are health plans, Medicare Advantage plans, and providers.
- Quality and Stars Solution suite that analyzes, communicates, and improves financial and clinical performance through Quality Intelligence, Star Intelligence, Medical Intelligence, and Medical Record Abstraction, supporting HEDIS measure certification and CMS Star Ratings. Sold to health plans and government programs.
- Eliza Member Engagement Multi-channel member outreach and engagement platform that drives member action and improves health outcomes, leveraging 25+ years of member engagement experience. Used by health plans to improve quality measure compliance and member participation.
- Engagement Hub Configurable member engagement workflow platform launched in January 2025 that empowers health plans to drive member outreach through multi-channel communication capabilities.
- Edifecs Healthcare Interoperability Cloud Healthcare data interoperability platform providing cloud-based SaaS solutions for claims submission, eligibility and member enrollment, FHIR-based data exchange, and CMS interoperability compliance. Serves nearly 300 million people in the U.S. healthcare market. Acquired by Cotiviti in March 2025.
- AI-Driven Population Payment Management Platform AI-driven platform unveiled by Edifecs in September 2025 for value-based payment contract administration. Enables customers to accelerate value-based care adoption and obtain more complete and accurate care funding.
- Cotiviti GOV Services Government healthcare solutions unit providing CMS Recovery Audit Contractor (RAC) services for Medicare Regions 3, 4, and 5, identifying improper Medicare payments and program integrity work.
- Cotiviti Retail Data management and recovery audit business for the retail industry covering supplier audit reviews, contract compliance, and overpayment recoveries. Sells to mass merchants, grocery and drugstore chains, specialty retailers, and Fortune 1000 companies.
- Zero Hour Alerts Web-based preventive analytics platform for retail payment accuracy that intercepts margin loss prior to transaction or within 90 days. Uses proprietary rules built on 40+ years of retail industry experience to monitor procure-to-pay processes.
Quantifiable outcome
- 45% increase in program value for healthcare payer clients using prepay DRG review
- +8 more outcomes
Companies that use Cotiviti
Customer profileNamed customers7 records
Segments6 records
Ideal customer profiles4 records
Cotiviti technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- No
- API docs
- API detail
Core technology
AI maturity
App detail
Integration1 record
AI capability8 records
Feature7 records
Cotiviti partnerships and signals
Strategic signalPartnerships
One partnership is on record.
- EdifecscoreCotiviti completed acquisition of Edifecs in March 2025 for over $3 billion. Edifecs provides market-leading healthcare data interoperability technology serving nearly 300 million people in the U.S. healthcare market. The combined organization enables transformative advancements in value-based care, interoperability, and streamlined operations across payers and providers.
Scale indicators17 records
Recent moves6 records
Expansion highlights6 records
Cotiviti competitors and assessment
Company assessmentDirect peers
- MultiPlan: MultiPlan is a healthcare cost management company offering payment integrity, network management, and analytics services. It is one of Cotiviti's closest direct competitors in the payer market.
- Zelis: Zelis provides healthcare claims cost management and payment integrity solutions to payers, directly competing with Cotiviti in prepay/postpay editing, fraud detection, and cost containment analytics.
- Inovalon: Inovalon provides cloud-based healthcare data analytics and platform solutions for payers, providers, and pharmacies, directly competing with Cotiviti in risk adjustment and quality analytics.
- Waystar: Waystar is a healthcare payments and revenue cycle technology platform serving payers and providers. Ric Sinclair joined Cotiviti from Waystar, and the two compete in payment and claims workflow solutions.
- Healthcare IP: Healthcare IP specializes in payment integrity and fraud detection for healthcare payers, directly competing with Cotiviti's payment accuracy and FWA solutions.
Emerging players
- Health Catalyst: Health Catalyst provides healthcare data and analytics solutions to providers and payers, with growing overlap with Cotiviti in quality measurement, risk adjustment, and population health analytics.
- Datavant: Datavant provides healthcare data connectivity and interoperability solutions. Following Cotiviti's Edifecs acquisition, Datavant is a relevant adjacent competitor in payer-provider data exchange.
Broad incumbents
- Change Healthcare: Change Healthcare (now part of Optum) provides a broad suite of revenue cycle, payment integrity, and analytics solutions for payers and providers, overlapping with Cotiviti's core offerings.
- Optum (UnitedHealth Group): Optum is the largest healthcare analytics and services platform in the U.S., with overlapping capabilities in payment integrity, risk adjustment, and claims analytics. It competes with Cotiviti across most payer-facing solutions and was reportedly a bidder for Edifecs.
Others
- Clarity Insights (now part of Accenture): Clarity Insights (acquired by Accenture) provides healthcare data analytics consulting and implementation services, adjacent to Cotiviti's payer analytics platform and often a systems integrator partner or competitor for analytics engagements.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat6 records
Key risks6 records
Key highlights7 records
Customer concentration
Cotiviti social profiles
Digital presenceCotiviti compliance and trust
Trust signalCompliance1 record
Cotiviti financial estimates
Financial estimateRevenue estimate
Valuation estimate
Cotiviti leadership team
Management profileNumber of profiles
Profiles5 records
Cotiviti subsidiaries and ownership
Company hierarchySubsidiaries1 record
Cotiviti funding detail
Funding detailFunding overview
Funding rounds1 record
Investors2 records
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
Cotiviti M&A and investment
M&A and investmentM&A2 records
Investments
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about Cotiviti
What does Cotiviti do?
Cotiviti is a healthcare analytics company that provides payment accuracy, risk adjustment, quality measurement, and member engagement solutions to healthcare payers, government programs, and providers. Through its 2025 acquisition of Edifecs, it also delivers healthcare data interoperability cloud solutions. A separate Cotiviti Retail unit supplies recovery audit, contract compliance, and payment accuracy services to retail and enterprise clients.
Is Cotiviti a public or private company?
Cotiviti is a private company. It is classified as private equity controlled and is currently operating.
When was Cotiviti founded?
Cotiviti was founded in 1979. It employs 5,001 to 10,000 people.
Where is Cotiviti based?
Cotiviti is headquartered in Atlanta, United States, in the North America region.
How does Cotiviti make money?
Three revenue lines are on record. Healthcare Software and Analytics Services are the primary driver. The others are CMS Recovery Audit Contractor Services and retail Audit Services.
Who are Cotiviti's main competitors?
Direct peers on record are MultiPlan, Zelis, Inovalon, Waystar and Healthcare IP. Emerging players are Health Catalyst and Datavant. Broad incumbents are Change Healthcare and Optum (UnitedHealth Group). Clarity Insights (now part of Accenture) is listed as an others.
Does Cotiviti have an API?
No public API is recorded for Cotiviti.
What industry is Cotiviti in?
Cotiviti's product category is Healthcare Payment Integrity Analytics. Its primary akta.pro industry code is HLALABAM, Revenue Cycle, Coding & Telehealth Compliance Platforms (for provider orgs), with a secondary code of HLACALAL, Quality, Peer Review & Compliance Tools (MQSA/ACR/QA). Its NAICS code is 518 and its SIC code is 7372.