AI Solutions for Healthcare

If you’ve been following Codoxo’s published insights, you may have noticed that we’ve been beating a steady drum about an exciting transformation underway within healthcare payment integrity.  

Healthcare organizations are in a heightened state of alert about spiraling fraud, waste and abuse (FWA) and its negative impact to their bottom lines. As sky-high costs continue plaguing the industry, a growing number of healthcare payers, agencies and pharmacy benefits managers are adopting newer cost containment approaches that augment traditional post-pay strategies with pre-pay programs to keep unwanted FWA-related costs from popping up. 

But doing so requires the right technologies – and this is where artificial intelligence (AI) and machine learning (ML) are helping to re-engineer how provider education is done within payment integrity programs. Traditionally, provider education has been handled reactively and manually, eating time and resources while also stoking payer-provider abrasion (for more detail, read our recent blog, “3 Ways AI is Transforming Provider Education for Greater Payer-Provider Education and Reduced Healthcare Costs“).

AI changes the game. Instead of burning precious time on labor intensive processes, healthcare organizations are turning to more efficient, automated workflows to identify outliers much earlier in the process. By leveraging advanced solutions such as Provider Scope, one of six solutions built atop Codoxo’s Unified Cost Containment Platform, healthcare payers are revamping their pre-claim submission processes with AI capabilities that fuel greater “shift-left” movement toward more holistic payment integrity. 

While preventing claim errors before they even start is now possible, there’s more work to be done. Healthcare payment systems still need to be more efficient, support enhanced data interoperability and systems integration, and reliably reduce costs. AI-based provider education is one area that begins to address these objectives. 

5 Steps Toward AI-based Provider Education

How can you leverage AI-based provider education to improve payment integrity? Here’s a look at five best practices to get started.  

1. Go big with data strategy 

Many fraud detection systems only analyze certain claim types. But excluding even one claim type will create a gap in provider practice patterns – leading to missed opportunities. This means you need a comprehensive view across the payment spectrum. The ability to ingest and integrate all claims, including professional, facility and pharmacy claims, will help ensure you’re able to promote coding best practices and reduce costs pre-claim. It’s also important for your claim type analysis to go beyond the basic E&M code modifiers. If you only look at these basic codes, you’ll have a pretty narrow view of both the health plan and the provider.  

2. Make information easy to access

Accessible, user-friendly data can be a game changer for accurate payment integrity. While having tools to identify outliers earlier in the process is critical, it’s not enough if provider billing teams and other stakeholders don’t use your system because it’s too complex or poorly designed. Providers should be empowered with simplified access to an online portal with powerful data visualizations that are relevant, easy to interpret and actionable, with the most current coding guidelines included.

3. Monitor provider engagement  

No matter how easy you make it, some providers may be reluctant to engage with the portal at first. Monitor and communicate with these providers, especially after receiving a letter identifying outlier behavior. If there’s still no engagement, take the outreach up a notch to garner attention. This might mean sending emails and letters about the platform and its importance. Create a collaborative environment: include all stakeholders and solicit their input. Giving everyone a voice in the payment integrity process can dramatically improve engagement. 

4. Create automation and efficiencies  

AI can provide a wealth of information: timely insights into coding standards, mandates, best practices and peer benchmarking that helps providers avoid costly errors and mistakes. It also allows you to compare providers on multiple levels by creating true peer groups and establishing a baseline for each group. System-generated themes can include identified egregious billing patterns aggregated into common or top themes based on paid exposure amounts, with flagged providers and claims contributing to outliers – all which can be more deeply explored. You can even create customized provider campaigns based on theme data.

It doesn’t end there. AI also can be used for self-monitoring, tracking historical trends and resolving coding errors – and it’s all automated!

5. Keep improving your campaigns

The programs and campaigns you develop must continue to evolve to remain effective. Determine which providers will monitor the solution to ensure the right benchmarks are being tracked, and establish a set of benchmarks to determine who moves on and off the education list. We recommend building a set of themes to evaluate and campaign around for continuous improvement. 

Transforming healthcare payment integrity with AI innovation

The model for cost containment is changing. Forward-thinking health plans are now leveraging AI and machine learning to ensure payment integrity throughout the entire process. Outliers found much earlier in the cycle are not only better for business and patient outcomes, but also cuts down the huge amount of FWA reported each year. 

Codoxo’s award-winning AI-based Unified Cost Containment Platform offers critical provider education focused on coding, billing, payment policies, and best practices. It analyzes complex codes while providing a much broader look at coding and billing patterns for superior insight into provider performance, all of which is key for improving efficiencies and avoiding FWA. 

Most importantly, it helps providers to be proactive. By reducing the time, resources, and stress levels of everyone involved in payment integrity, the healthcare industry continues to transform.   

Learn more 

For a more comprehensive look at how leading-edge AI is evolving provider education, click here to read the full white paper, “The Quest for Modernized Healthcare Payment Integrity: A Case For AI-Driven Provider Education & Collaboration.”

To learn more about how Codoxo is transforming healthcare, or to speak to a Codoxo team member, email us at


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