AI Innovations Enable Payers to Lower Administrative and Medical Loss Ratios, Scale Value-Based Care, and Optimize Financial Performance
Edifecs, a Cotiviti business and a leader in healthcare data interoperability, announced the next-generation Population Payment Management platform powered by agentic artificial intelligence (AI). The upgraded solution provides a practical, scalable application of AI to tackle longstanding challenges in healthcare value-based payment (VBP) transformation.
At the heart of Edifecs’ VBP processing platform, agentic AI uses intelligent, task-focused “agents” that understand healthcare payment objectives and the intricacies of VBP program design. These agents actively monitor context to trigger appropriate workflows, generate real-time insights, and perform comprehensive workflow analyses end-to-end. By automating traditionally resource-intensive tasks, organizations can scale value-based programs more efficiently, reduce administrative costs, and access timely, actionable intelligence to support informed decision-making. The platform’s enhanced capabilities improve settlement speed and accuracy, helping lower both administrative and medical loss ratios while boosting financial performance for healthcare payers.
Edifecs emphasizes responsible AI deployment with human oversight, ensuring that agents complement healthcare professionals’ expertise rather than replace it, while adhering to strict data privacy, transparency, and regulatory compliance standards. Notably, these AI agents are never used for clinical decision-making or medical necessity assessments. Instead, they are specifically designed to optimize VBP contract design and settlement, streamline workflows, and deliver clear insights on contract performance and financial outcomes.
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“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. Two-sided risk models, where providers share both savings and losses, grew to 28.5%. Despite this growth, many organizations face challenges scaling VBP contracts without overburdening administrative budgets, and performance monitoring remains a critical barrier.
Edifecs’ enhanced platform introduces three specialized AI agents to transform how healthcare organizations manage value-based payment programs. Central to the solution is Virtual Jonathan (VJ), a next-generation data analyst agent that provides natural language access to contract terms and performance metrics. VJ allows users to explore Population Payment Management data in real time, answer ad-hoc questions, and generate operational analytics on demand without SQL, coding, or complex report building.
VJ is supported by two additional agents:
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Dashboard Agent – Converts natural language queries into fully customizable dashboards, enabling conversational, interactive analytics tailored to individual users.
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Deep Research Agent – Proactively identifies trends, variances, and performance risks, providing guided recommendations to enhance financial, quality, and operational outcomes.
Together, these agents transform Population Payment Management into a dynamic, conversational analytics platform, empowering payers and providers to act with speed and precision. Future updates will enable deep research agents to coordinate multiple AI agents through a model context protocol to address complex analytical challenges that previously required entire teams and extended timeframes.
Following Cotiviti’s acquisition of Edifecs on March 31, 2025, the launch of these AI-powered capabilities highlights the combined expertise of both organizations. By integrating Cotiviti’s leadership in data analytics and payment accuracy with Edifecs’ strengths in interoperability and value-based care, the companies are delivering solutions that enhance efficiency, support alternative payment model growth, and improve healthcare delivery and patient outcomes.
