To: Board of Supervisors
From: Dr. Grant Colfax, Health Services Director
Report Title: Contract Amendment #27-791-15 with Cotiviti, Inc.
☒Recommendation of the County Administrator ☐ Recommendation of Board Committee
RECOMMENDATIONS:
APPROVE and AUTHORIZE the Health Services Director, or designee, to execute on behalf of the County Contract Amendment #27-791-15 with Cotiviti, Inc., a corporation, effective April 14, 2026, to amend Contract #27-791-14, to increase the payment limit by $2,250,000, from $3,000,000 to a new payment limit of $5,250,000, for code editing and validation capabilities concerning its hosted software solution for analyzing Healthcare Effectiveness Data and Information Sets (HEDIS) for fraud, waste and abuse for Contra Costa Health Plan (CCHP) with no change in the term November 1, 2025 through October 31, 2028.
FISCAL IMPACT:
Approval of this Contract Amendment will result in additional annual expenditures of up to $2,250,000 as budgeted by the department and funded 100% by CCHP Enterprise Fund II revenues.
BACKGROUND:
This Contract meets the needs of the County by providing proprietary data analysis software for HEDIS projects and reports to support State and contractual requirements for CCHP. Cotiviti, Inc., provides its licensed program, Quality Intelligence, used by CCHP to calculate and analyze HEDIS measures. HEDIS Measures, are a requirement for accreditation certification with the National Committee for Quality Assurance (NCQA) and mandated by the Department of Health Care Services, for which CCHP is assessed. HEDIS scores are used to determine Plan assignment, and therefore impact capitation payments from the state. HEDIS is also utilized for Quality Rate Factor payments in which capitation is not only based on monthly membership numbers but also HEDIS scores in comparison to other Plans. HEDIS is a heavily structured, highly audited process and calculations will not be accepted without the use of NCQA certified software to process the data. Under this Contract, Cotiviti provides the NCQA software to process the data.
On October 21, 2025, the Board of Supervisors approved Contract #27-791-14 with Cotiviti Inc., in an amount not to exceed $3,000,000 for the provision its hosted software utilized by CCHP to analyze healthcare effectiveness and identify fraud, waste and abuse for the period November 1, 2025, through October 31, 2028.
Approval of this Contract Amendment #27-791-15 will allow the Contractor to provide additional hosted software solution and services regarding code editing and validation capabilities concerning its Quality Intelligence Application Service Provider (ASP), a HEDIS-licensed program and data analysis solution which aids in identifying fraud, waste, and abuse schemes affecting CCHP through October 31, 2028. The expanded functionality includes advanced analytics that are not available within Epic, enabling automated denial or pended review of claims based on complex coding rules and clinical criteria. By preventing payment of claims that do not meet required conditions, this enhancement is expected to generate significant cost savings for the Health Plan and reduce millions in avoidable expenditures.
Under this Contract Amendment, Cotiviti’s liability, including its indemnity obligations, is limited to the amount paid by County under the Contract except for bodily injury, death, fraud or criminal acts by Cotiviti, which is not capped, and any claims that an unauthorized party accessed protected health information in the Cotiviti-hosted system, which is capped at $5,000,000. The Contract requires Cotiviti to maintain $5,000,000 in cyber-liability insurance.
CONSEQUENCE OF NEGATIVE ACTION:
If this Contract Amendment is not approved, County will not have access to Contractor’s data analysis software solution, nor funds to reimburse providers per requirements from Department of Managed Healthcare (DMHC) and DHCS, which will negatively impact CCHP’s ability to operate and ultimately, patient care.