Cotiviti

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.

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

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

• Payment integrity
• Healthcare analytics
• Risk adjustment
• Quality measurement
• Retail audit

Headquarters

HQ city

Atlanta

HQ country

United States

HQ region

North America

Offices4 records

Markets served

GTM type

B2B

Offering type

Software

Cost components

Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure

Revenue model

1. 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.
2. CMS Recovery Audit Contractor Services: Government contracts for Medicare Regions 3, 4, and 5 RAC audits including DME-related audits, representing recurring government revenue.
3. Retail Audit Services: Recovery audit, contract compliance, and payment accuracy services for retail sector clients including Fortune 1000 companies.

Pricing tiers

Go-to-market motion3 records

Distribution channels4 records

Marketing channels7 records

Core 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

Named customers7 records

Segments6 records

Ideal customer profiles4 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration1 record

AI capability8 records

Feature7 records

Partnerships

One partnership is on record.

• EdifecscoreStrategic or Co-development Partner · 31 March 2025Cotiviti 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

Direct 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

• Xx.com/Cotiviti

Compliance1 record

Revenue estimate

Valuation estimate

Number of profiles

Profiles5 records

Subsidiaries1 record

Funding overview

Funding rounds1 record

Investors2 records

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A2 records

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Cotiviti