Edifecs, a Cotiviti business specializing in healthcare data interoperability, has unveiled the next generation of its Population Payment Management platform, now powered by agentic artificial intelligence (AI), designed to address persistent challenges in healthcare value-based payment (VBP) transformation.
The core of Edifecs’ VBP processing platform leverages agentic AI, utilizing intelligent, task-oriented “agents.” These agents are programmed to understand healthcare payment objectives and the intricate nuances of VBP program design. They actively monitor context, trigger appropriate workflows, generate real-time insights, and execute complex workflow analyses from beginning to end.
These AI agents are intended to automate traditionally resource-intensive tasks, enabling healthcare organizations to scale value-based programs more rapidly, reduce administrative costs, and acquire timely, actionable intelligence to support informed decision-making. By improving the accuracy and speed of settlement processes, these agents aim to reduce both administrative and medical loss ratios, potentially enhancing financial performance for healthcare payers. Edifecs emphasizes a responsible deployment approach for its agentic AI, incorporating human oversight to ensure that agents augment, rather than replace, the expertise of healthcare professionals, while strictly adhering to data privacy, transparency, and regulatory compliance standards. The AI agents are explicitly not used for clinical decision-making or medical necessity determinations; their purpose is to power VBP contract design and settlement, streamline value-based care (VBC) workflows, and deliver clear, actionable insights on contract performance and financial outcomes.
Venkat Kavarthapu, Executive Vice President of Operations at Edifecs, commented on the development, stating, “Value-based payments are essential to building a more sustainable healthcare system, but operational complexity has slowed progress. 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.”The Health Care Payment Learning and Action Network (HCP-LAN) reported that value-based arrangements constituted approximately 45.2% of U.
S. healthcare payments in 2023, an increase from 41.3% in 2022. Within these arrangements, models involving two-sided financial risk, where providers share in both savings and losses, grew to 28.5%. Despite this growth, many organizations still face difficulties in scaling value-based payment contracts without escalating administrative budgets, and effective performance monitoring remains a significant obstacle. These challenges can limit their capacity to confidently assume additional risk.
Edifecs’ enhanced Population Payment Management platform integrates three specialized AI agents to optimize the management of value-based payment programs. Central to this offering is Virtual Jonathan (VJ), a data analyst agent that provides teams with natural language access to contract terms and performance metrics. VJ enables users to explore Population Payment Management data in real time, obtain answers to ad-hoc questions, and generate operational analytics on demand, eliminating the need for SQL, coding, or complex report building.
VJ is supported by two additional agents: the Dashboard Agent, which instantly converts natural language requests into customizable dashboards for conversational, interactive analytics tailored to individual users, and the Deep Research Agent, which proactively identifies key trends, variances, and performance risks, offering guided recommendations to improve financial, quality, and operational outcomes. These agents collectively transform Population Payment Management into a dynamic, conversational analytics platform, empowering payers and providers to act with speed and precision. A future update will enable deep research agents to coordinate multiple AI agents via a model context protocol to solve complex analytical challenges that typically require extensive team effort and time.
This launch of new AI-powered capabilities follows Cotiviti’s acquisition of Edifecs, completed on March 31, 2025. The integration was intended to expand and accelerate the development of innovative healthcare technologies. This initiative reflects the combined expertise of both organizations, merging Cotiviti’s leadership in data analytics and payment accuracy with Edifecs’ strengths in interoperability and value-based care. The unified effort aims to advance solutions that enhance efficiency, foster the growth of alternative payment models, and improve healthcare delivery and patient outcomes.
