AI Innovations Enable Payers to Lower Administrative and Medical Loss Ratios, Scale Value-Based Care, and Optimize Financial Performance
Edifecs, a Cotiviti business and pioneer in healthcare data interoperability, today announced the next generation of its Population Payment Management platform powered by agentic artificial intelligence (AI). The enhanced solution delivers a practical, scalable application of AI to address some of the most persistent challenges in healthcare value-based payment (VBP) transformation.
At the core of Edifecs’ VBP processing platform, agentic AI leverages intelligent, task-oriented “agents” that understand healthcare payment objectives and the nuances of VBP program design. These agents actively monitor context to trigger the correct workflows, generate real-time insights, and execute complex workflow analyses end-to-end. The agents automate traditionally resource-intensive tasks—enabling organizations to scale value-based programs faster, lower administrative costs, and gain timely, actionable intelligence to support confident decision-making. By improving settlement accuracy and speed, these agents can reduce both administrative and medical loss ratios, enhancing financial performance for healthcare payers.
Edifecs’ approach to agentic AI prioritizes responsible deployment with human oversight, ensuring agents augment – rather than replace – healthcare professionals’ expertise while maintaining strict data privacy, transparency, and regulatory compliance standards. Importantly, these AI agents are never used for clinical decision-making or medical necessity determinations. Instead, they are purpose-built to power VBP contract design and settlement, streamline VBC workflows, and deliver clear, actionable insights on contract performance and financial outcomes.
“Value-based payments are essential to building a more sustainable healthcare system, but operational complexity has slowed progress,” said Venkat Kavarthapu, EVP of operations at Edifecs. “By embedding intelligent agents directly into our Population Payment Management platform, we’re helping our customers scale programs faster, cut costs, and improve performance. This marks a shift from theoretical AI to practical solutions that understand the nuances of value-based contracts while processing healthcare data securely, at scale, and in compliance with industry standards.”
According to the Health Care Payment Learning and Action Network (HCP-LAN), value-based arrangements accounted for approximately 45.2% of U.S. healthcare payments in 2023, up from 41.3% in 2022. Within these arrangements, models with two-sided financial risk—where providers share in both savings and losses—rose to 28.5%. Despite this progress, many organizations continue to struggle with scaling value-based payment contracts without straining administrative budgets, and effective performance monitoring remains a major barrier. These challenges limit their ability to take on additional risk with confidence.
Edifecs’ enhanced Population Payment Management platform introduces three specialized AI agents that transform how healthcare organizations manage value-based payment programs. At the center is Virtual Jonathan (VJ), a next-generation data analyst agent, that gives teams natural language access to contract terms and performance metrics. VJ lets users explore Population Payment Management data in real time, answer ad-hoc questions, and generate operational analytics on demand, with no SQL, coding, or complex report building required.
VJ is augmented by two additional agents:
- Dashboard Agent – Instantly converts natural language requests into fully customizable dashboards, enabling conversational, interactive analytics tailored to each user
- Deep Research Agent – Proactively surfaces key trends, variances, and performance risks, delivering guided recommendations to improve financial, quality, and operational outcomes
Together, these agents transform Population Payment Management into a dynamic, conversational analytics platform that empowers payers and providers to act with speed and precision.
In a future update, deep research agents will coordinate multiple AI agents through a model context protocol to solve complex analytical challenges that typically require entire teams and significant time to complete.
On March 31, 2025, Cotiviti completed its acquisition of Edifecs to expand and accelerate the development of innovative healthcare technologies. The launch of these new AI-powered capabilities reflects the combined expertise of both organizations, bringing together Cotiviti’s leadership in data analytics and payment accuracy with Edifecs’ strength in interoperability and value-based care. Together, the companies are advancing solutions that improve efficiency, support the growth of alternative payment models, and enhance healthcare delivery and patient outcomes.
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