AI Solutions for Healthcare

Perhaps more than any other time in recent history, healthcare stands at a pivotal nexus between its legacy past and a more promising future. While the industry continues to battle pressures from rising costs, ongoing regulatory changes, and elevated expectations for faster, more retail-like customer experiences, we see encouraging signs of digitization and transformation happening across providers, payers, and agencies.

One notable change is the push towards smarter healthcare cost containment to address rising, out-of-control costs.  Researchers from McKinsey and Harvard estimate that nearly a quarter of the nation’s $265 billion in healthcare overhead costs could be cut with interventions that simplify processes and reduce unnecessary spend. By leveraging next generation artificial intelligence (AI) and machine learning, forward-thinking health plans are working to mitigate FWA and ensure payment integrity across the payment spectrum, including a focus on “shifting left” to identify outlier behavior and improve claim integrity earlier in the payment cycle.

AI-driven provider education curtails healthcare costs

Healthcare payers have traditionally undertaken provider education on an ad-hoc basis, mostly relying on physical letters generated by special investigations units (SIUs) or payment integrity teams upon finding a coding or billing anomaly. Often, this process is highly laborious and consumes significant resources to data mine, analyze and report on outlier behavior. Not to mention it is a reactive approach to working with providers to improve coding and billing practices.

With the help of AI, healthcare organizations can transform traditional labor intensive processes into efficient, automated workflows. Codoxo’s AI-based platform offers a proactive and comprehensive experience that educates providers about coding, billing, and payment policies and best practices – avoiding errors before they even start. Here are three ways AI is helping to automate provider education and curtail healthcare costs:

#1. AI empowers a “shift left” approach by improving claim integrity earlier

Thanks to AI-driven forensic analysis, Codoxo enables health plans to inform and educate providers about guidelines, best practices and policies for a proactive approach to improving claim integrity. Our AI technology analyzes multiple dimensions of billing behavior to detect problematic trends (i.e., telehealth, add-on codes, psychotherapy) earlier in the payment lifecycle and shares provider coding and billing performance with the health plan and directly with providers. Earlier awareness of performance trends and insights empowers not only the health plan but the providers to shift behavior toward more compliant coding and billing practices.

 Engaging with providers on an ongoing basis, especially before claims are submitted, enables health plans to avoid payment delays, costly audits, and wrongful claims submissions across the payment spectrum – all of which drives down costs.

#2: AI fuels comprehensive performance insights and proactive monitoring

For healthcare payers and providers alike, Codoxo delivers a new level of transparency and performance insight fueled by advanced AI, data and analytics. Codoxo’s Unified Cost Containment platform ingests all claim types including nearly 10,000 Current Procedural Terminology (CPT) codes used for medical billing purposes. Traditional analysis is often restricted to E&M codes only, which creates a highly narrow view into overall performance and opportunity. A more comprehensive approach gives payers access to integrated cross-claim analysis and holistic views across their networks. Using Codoxo’s Provider Scope, health plans and network teams can monitor providers, comprehensively identify issues across all codes, and share trends and insights with provider billing staff. 

Providers are similarly empowered. By logging into an intuitive provider portal, they are provided visually-rich graphs and side-by-side charts of coding and billing performance. Dashboards include peer-to-peer comparison based on predetermined peer groups, performance trends, outlier behavior and areas in need of attention. This new self-service access to data and analytics gives providers the ability to monitor and self-correct their coding and gain insight from peer benchmarking for more compliant billing.

#3. AI helps improve payer-provider collaboration

It’s no secret that billing audits and investigations have caused significant abrasion between payers and providers. Codoxo is changing this dynamic. Less friction exists when providers are continuously trained on current coding and billing best practices and health plan policies. Sharing performance reporting directly with providers enables providers to feel empowered and can help them quickly modify behavior if needed. This open communication helps keep compliance and reduces outlier coding and billing patterns. In turn, providers are paid on time without interruption to payments due to lengthy audits and reviews.

One health plan generated measurable outcomes in four weeks

A health plan wanted to take its FWA performance to the next level by adopting AI-based provider education and compliance within its SIU. The goal was to improve billing behavior upstream in the payment process to achieve pre-claim savings, cost avoidance, and overall improved billing and payment accuracy. 

Expanding upon its use of Codoxo’s Fraud Scope, the health plan’s SIU team implemented Provider Scope to identify providers with outlier coding and billing patterns and learn who may benefit from further education. By focusing on an initial pilot program with select parameters, which included the top 5% of egregious providers, emphasis on E&M codes only, and outreach letter campaigns to providers, the health plan achieved the following impressive results in just four short weeks: 

  • 15% of providers utilized the portal upon receipt of an education letter 
  • Provider abrasion​ eliminated
  • $40K+ in savings​
  • Smooth rollout and open communication​

After only three months, the health plan has expanded this project beyond the initial pilot to include the top 10-15% of egregious providers and plans to migrate to additional themes.


Codoxo shows what’s possible when AI-powered provider education is integrated into a healthcare organization’s payment integrity program. 

Codoxo’s Unified Cost Containment Platform offers a remarkable ability to do what seemed impossible a few short years ago: break down silos, automate laborious tasks and workflows, improve operations, and affect behavior change – all of which drives down costs and maximizes savings. By using AI to scan vast volumes of healthcare data, detect outliers early and accurately, and transform provider coding and billing education, we’re helping healthcare payers realize ROI quickly.

Let’s Connect

For deeper insights into how Codoxo is deploying AI-driven solutions to improve healthcare payment integrity, reduce provider-payer abrasion, and lower overall costs, please click here to download our recent white paper, “The Quest for Modernized Healthcare Payment Integrity: A Case For AI-Driven Provider Education & Collaboration.”

To learn more about Codoxo and how our team is transforming healthcare, or to speak to a Codoxo team member, please contact us at


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