Healthcare payers are feeling the pressure to achieve greater cost containment, and are tasked with reducing the fraud, waste and abuse that costs the U.S. at least $114 billion every year. To that end, they’re shifting from the traditional cost-containment methods of the past to technologies like artificial intelligence (AI) and automation that are shaping the industry’s future.
In a recent Impact Report, Aite Group not only outlines the three major trends specific to healthcare claims that are impacting the payment integrity market, with an increased focus on technology among them, the global research and advisory firm also takes a close look at the vendors playing the biggest role in moving the industry forward—including Codoxo.
The Aite Matrix: Payment Integrity in Healthcare report analyzes how technologies are evolving to address new market needs and challenges, comparing vendors based on four key metrics: vendor stability, client strength, client service and product features. The report also highlights each company’s offerings, strategies, strengths and challenges.
As the youngest company included in the report, Codoxo’s fraud, waste and abuse AI solution was named a Leading Contender that’s gaining in strength and industry prominence.
“As a newcomer to the payment integrity vendor landscape, Codoxo is a small but mighty player that comes from academic roots with forward-looking AI skills,” wrItes Inci Kaya, senior analyst and author of the report. “The vendor is likely to disrupt the market between its strong data dashboard visualization capabilities and willingness to work with new accounts or potential accounts.”
Here’s a look at the three trends the report identifies, as well as why Codoxo is recognized as an emerging leader in the ever-evolving payment integrity market.
1. Consolidation is shrinking the competitive landscape. This is happening in multiple areas, according to the report, including vendor M&A, health plans, healthcare systems and atypical or non-traditional technology from other sectors.
“Continued consolidation of payment integrity vendors via M&A creates a more competitive market from a capability and pricing perspective,” Inci writes. “More consolidation will occur as smaller vendors look to compete with larger vendors and as large vendors look to fill solution gaps quickly.”
2. Regulatory changes are leading to updated rules. Data privacy as well as security laws continue to increase in complexity and scope, shaping the regulatory landscape.
There are a variety of factors leaving vendors and health plans to “face a host of regulatory changes in the future,” according to the report. They include:
- A new presidential administration
- Changes and updates to the Centers for Medicare and Medicaid Services’ (CMS’) guidance regarding Medicare and Medicaid
- The role of the Affordable Care Act in cost-containment efforts
- Medicaid expansion leading to an increase in overall insured individuals
- Price transparency
- Interoperability measures
3. As technology advances, companies will have to boost R&D investments. Technologies like automation, AI, machine learning (ML), electronic health records (EHR), and electronic medical records (EMR) are “the order of the day,” according to the report. Cloud services are also becoming more common, while “integration and demand for real-time processing are imminent.”
Technology partners are continually investing and reinvesting in technology capabilities, according to the report, with 38% of vendors investing more than 15% of their revenue in R&D. Another 25% report an average investment of 10% to 15%.
While these are the top trends, the report also notes other critical factors influencing the industry, including:
- A reliance on robust data strengths
- A priority on reducing provider abrasion
- A shift to pre-pay evolving with audits and claims reviews
- A focus on increased accuracy
- A rise in identity fraud
- Payer provider collaboration becoming a mainstay
- Emerging business and reimbursement models reshaping go-to market strategies
A Leading Contender
Of the vendors included in the report, some with 40 years in the industry, Codoxo is recognized as a leading contender and a fast-growing technology provider that stands out in an environment filled with large competitors.
“Unlike other payment integrity vendors, Codoxo’s roots come from a leading academic research group at a top university,” Inci writes in the report. “The company, borne out of the Georgia Institute of Technology, brings its expertise in AI and cybersecurity together with its passion for addressing the challenge of healthcare FWA costs. Its groundbreaking work helped build the Forensic AI Platform, which accurately and quickly detects risks and costs, especially those previously unforeseen.”
The report lists Codoxo’s services, noting an increased client demand for Provider Scope, the company’s automated provider education and self-monitoring portal created to reduce outlier behavior that includes certified coders and clinical staff who can field questions from providers.
The Power of AI
Healthcare leaders are turning to self-learning AI for a holistic approach to cost containment—and that’s an area where Codoxo shines. AI can uncover existing problems and detect others bubbling under the surface, while enabling fraud prevention teams to quickly make decisions so they can act faster.
As the report notes, “Codoxo is very forward-looking and open to applying new concepts. It provides an integrated solution that includes analytics and case management, and the product optimizes client resources and is highly customizable. It offers leading AI and demonstrates strength in areas of design, development, coding and production.”
This perhaps sums it up best, with Inci describing Codoxo as a “small but mighty technology solution, with AI in its DNA and powerful data analytics muscle wrapped in a user-friendly interface.”
Payment Integrity Market Trends: What You Need to Know
The Aite Matrix: Payment Integrity in Healthcare report from the Aite Group outlines major trends and compares top vendors in the industry—with Codoxo standing out among them.
“Codoxo is a small but mighty technology solution, with AI in its DNA and powerful data analytics muscle wrapped in a user-friendly interface.”
– Inci Kaya, senior analyst and author of Payment Integrity in Healthcare report
3 Major Payment Integrity Market Trends:
The competitive landscape is consolidating.
Regulatory changes demand updates to rules.
Technology advances mean emphasizing R&D investments.
How Codoxo Compares
4 key metrics used to compare
vendors in the report:
1. Vendor stability
2. Client strength
3. Client service
4. Product features
Codoxo’s Key Product Features, As Noted in the Report:
Transparency pointing to source data
Customized reports and dashboards
Self-service data filtering, viewing, querying, reporting, exporting and document gathering
A dashboard that presents a running tally of recoveries and savings, prevented losses, exposure amounts, and the statuses of cases for a real-time snapshot on the health plan’s exposure.
Case management, queries, customized reports and dashboards are part of the integrated base platform and do not require additional fees.
Aggregate views and drill-down views into claims
What Aite Group Has to Say About Codoxo:
“Codoxo’s groundbreaking work helped build the Forensic AI Platform, which accurately and quickly detects risks and costs, especially those previously unforeseen.”
“Codoxo is very forward-looking and open to applying new concepts. It provides an integrated solution that includes analytics and case management, and the product optimizes client resources and is highly customizable.”
“As a newcomer to the payment integrity vendor landscape, Codoxo is a small but mighty player that comes from academic roots with forward-looking AI skills. The vendor is likely to disrupt the market between its strong data dashboard visualization capabilities and willingness to work with new accounts or potential accounts.”
“Codoxo provides preset data to users, putting the payment integrity recovery within a click of a button for health plan users. The vendor can also run the health plan’s data through an algorithm that highlights trends or outliers, which is very useful.”
All quotes from Inci Kaya, senior analyst and author of Payment Integrity in Healthcare report.