AI Solutions for Healthcare
What to expect for AI, payment integrity, cloud data security, and more from Codoxo’s healthcare technology experts

Americans spend $3.8 trillion on health care – and it’s believed as much as 10% of health insurance claims are fraudulent. According to the National Health Care Anti-Fraud Association (NHCAA), only a small portion of that is identified and intercepted, resulting in higher insurance premiums and reduced benefits or coverage.

Fraud and abuse have long been an issue in healthcare, but recent developments have created a perfect storm, making the industry an even more vulnerable target for fraud and abuse. Relaxed telehealth mandates put into place during the COVID-19 pandemic, the increased digitization of health, emergence of direct to consumer (D2C) online services, and access to new technologies have made it easier than ever for fraudsters to operate are all contributing to a growing problem.

Healthcare continues to be fast-moving with an ever-evolving terrain ripe for opportunities for new types of fraud and abuse. That said, looking at this year’s most impactful trends provides insight into what to expect in 2022.

1. AI adoption and innovation continue to rise

While there has been much buzz about AI in the healthcare industry for the past several years, we are moving beyond an era of discussing its promise to an age of acceleration where we see rapid adoption, meaningful implementations, and actual returns. Health plans are rapidly adopting the use of AI to fight fraud, waste and abuse, streamline repetitive processes, automate workflows, and even to personalize member experiences.

According to recent HIMSS research reported by Healthcare Finance News, 53% of healthcare insurance executives say they are accelerating their AI and machine learning adoption. Although roughly half of healthcare payers have their own innovation labs, 53% believe healthcare startups will take a leadership role in driving industry innovation moving forward. And a 2021 KPMG survey reveals an even greater adoption rate – 67% of healthcare companies report using AI to solve challenges, including those caused by COVID-19.

“The reality is the healthcare industry is well on its journey of AI adoption,” says Musheer Ahmed, PhD, CEO and Founder at Codoxo. “The gating question for payers and providers now is, if they don’t have AI, what’s holding them back? Going forward, healthcare organizations need it – and are expected to have it.”

Ahmed adds that healthcare has traditionally been slower than other industries when it comes to adopting new solutions, in part because everything is so complex and regulated. “But AI is no longer all ‘smoke and mirrors’ as it was a few years ago with some solution providers,” he adds. “Now it’s expected, yet sometimes hesitation still lingers due to lack of understanding of what AI is and what it can do.”

While healthcare is slow to embrace technology relative to other market sectors, the industry is now in the midst of a tech revolution. Health plans and providers are implementing long-overdue technologies such as AI and innovating new solutions to improve patient care, streamline administrative functions, and contain costs. As adoption skyrockets and implementations mature, AI investments are poised to drive efficiency and meaningful returns on investment.

“AI increases transparency and visibility, making it easier for healthcare providers to have a better understanding of what’s happening among health plans with respect to costs and claims that are being submitted,” explains Ahmed. “Faster response times are essential, as is the need for greater collaboration and communication. All can be enabled by AI. This is important now and will become even more important in 2022.”

2. Telehealth transitions from pandemic response to standard care delivery platform

Within the first three weeks of the WHO declaring the COVID-19 pandemic, telehealth visits skyrocketed 154 percent, according to the CDC. After sharply peaking in April 2020, telehealth visits have leveled off, finding a new elevated steady state at approximately 20x higher than pre-COVID rates, according to anonymized health plan data from Codoxo.

But the rise of telehealth unfortunately brings with it increased fraud, waste, abuse and error, triggering an explosion of novel fraud schemes that continue to evolve. A 2021 study by Codoxo reveals that among the 41% of provider specialties showing statistically significant increases for telehealth adoption, up to 15% of telehealth claims are non-compliant with CMS guidelines.

“Any time we see significant changes in the healthcare industry and radical shifts in billing patterns, bad actors find a way to take advantage of those transitions, and the boom in telehealth was no exception,” adds Ahmed. “If healthcare payers, providers, and other industry leaders can quickly identify, investigate, stop and prevent suspicious telehealth claims and bad payments, the entire healthcare ecosystem benefits by avoiding massive, unnecessary, and otherwise avoidable costs.”

Saurav Subedi, Director of Data Science at Codoxo, predicts that telemedicine will continue in a measured way. “COVID-19 changed the landscape of who uses telehealth and in what capacity. New federal guidelines and changes in policies are continuing to emerge,” he explains. “This correlates to a change in billing patterns which generates emerging abusive schemes that need to be proactively monitored and controlled.”

Looking ahead, Subedi believes that the evolution and sustenance of telehealth will trigger important discussions on where it’s best used and how to sustain it. “Some specialties are naturally more suited for telehealth,” he notes. “This includes counseling sessions, behavioral health, psychiatry sleep medicine and elder care.

Rena Bielinski, Codoxo’s Vice President of Customer Success, elaborates on the increased use of telehealth for behavioral health purposes. “Mental and behavioral health are becoming increasingly standard telehealth services,” affirms Bielinkski. “Positive signs point to the inclusion of mental health as something that is integrated into how healthcare providers and plans support their patients. But as the telehealth trend continues, providers need to sharpen the focus on proactively managing fraud.”

Going forward, healthcare providers will continue transitioning telehealth from a stop-gap solution to a standardized care delivery platform with the proper infrastructure to support it. Instead of putting more barriers in place to telehealth during this transition, the industry is likely to embrace telehealth for its efficiencies while also seeking better barriers to growing fraud risks.

3. Predictive analytics paves the way for more cost-effective care

As healthcare continues to move toward a value-based system that aims to lower costs while improving quality, predictive analytics will be critical to drive efficiencies and effectively improve outcomes.

“There’s an industry-wide realization that healthcare needs to do things differently. Predictive analytics provide a path to more cost-effective care,” says Bielinski. “AI technology makes it possible for healthcare organizations to discover new and emerging fraud schemes before they’re fully robust and identified. And that’s huge, because it’s the time value of fraud identification that leads to increased savings.”

Electronic medical records (EMR) are another area that is vastly improving with AI. Prasoon Saurabh, Vice President of Engineering at Codoxo, predicts breakthrough impact for AI-based EMR technology on the horizon. “On the healthcare payer side, AI is beginning to play a significant role with EMRs when it comes to providing insights on medical records history prior to authorizing a procedure or test. Using AI in this way will boost efficiency and cost savings.”

Since predictive analytics is best achieved with a holistic view of corporate data, software integration is another area that will be important in 2022 according to Dr. Ahmed. “Historically software has always operated in silos across different teams and systems within health plan organizations,” says Ahmed. “Greater discussions are happening around API integrations, for example. Silos are beginning to break down – with more collaboration, communication and education across teams. It’s refreshing to see the industry head in that direction.”

Rajesh Razdan, Vice President of Products at Codoxo, thinks that moving from individual silos to single platform that supports different claim types and processes is crucial for unlocking new efficacies. “Health plans are realizing the importance of moving their multi-claim type data and processes to a single platform where AI and data are all in one place. “By moving data to one platform, healthcare payers can both manage the tactical steps of claims processing but also see trends from a big-picture view. In 2022, we expect to see more payers starting to evaluate vendor partnerships and platforms that make this a reality.”

4. Closer attention will be paid to payment integrity

A recent Aite Group report on healthcare payment integrity outlines three trends shaping the market: First, the competitive vendor landscape is consolidating. Second, regulatory changes demand updates to rules. And third, technology advances warrant a deeper focus on R&D investments.

In particular, technologies like automation, AI, machine learning, electronic health records and electronic medical records are increasing in demand. Cloud services, software integration, and real-time data processing are also requested more commonly, according to the report.

Within this context, Codoxo’s Razdan compares the rise of sales force automation with what’s ahead for payment integrity. “Payment integrity is in the same space where sales automation was 20 years ago – siloed business units working with isolated data sets,” he says. “The next order of business is to turn payment integrity into an enterprise platform – much like Salesforce – that unify disparate group activities. New technologies provide the underpinning of an exponential opportunity here. Applying the same predictive power of AI to other workflows will accelerate the benefits to be gained from automation and cross-team collaboration.”

5. Increasing cloud adoption brings a focus on data security

In the Gartner 2021 CIO Agenda Survey, cybersecurity was the top priority for new spending, with 61% of the more than 2,000 CIOs surveyed increasing investment in cyber/information security this year. As Gartner sees it, organizations continue to grapple with the security and regulatory demands of public cloud and software as a service. Looking ahead, early market signals indicate growing automation and further adoption of machine learning technologies in support of AI security.

For healthcare organizations, the correlation between more data residing in the cloud and the need for more data security is clear.

“The COVID-19 crisis has definitely accelerated cloud adoption by healthcare insurance companies,” says Saurabh, Codoxo’s Vice President of Engineering. He notes that many had been opting to build an in-house solution and deploy it into their own data center, but this takes time.

“Moving from a vendor-locked onsite solution to a more open cloud-based solution with software-as-a-service enables more rapid development,” Saurabh says. “At the same time, the move to the cloud puts more scrutiny on security regulations and requirements around digital healthcare information.”

6. Reducing payer-provider abrasion drives better outcomes

Collaboration fosters shared goals and greater successes, and this rings true when it comes to healthcare payer and provider relationships. According to a 2019 national survey cited by participants in a roundtable discussion hosted by the Healthcare Financial Management Association, about 77% of healthcare executives ranked their payer-provider alignment as a “one” or “two” on a five-point scale for collaboration. A 2021 Journal of AHIMA article also cites abrasion between providers and payers as an ongoing healthcare challenge.

That said, friction can be reduced by employing best practices rooted in sharing data and intelligence across the revenue cycle, making communication easier between payers and providers, and establishing policies and procedures to prevent denials and ensure claims are transmitted cleanly and with minimal delays.

“In 2022 and beyond, provider education and compliance programs using advanced AI-based fraud detection will be important for achieving a more efficient healthcare system, without adding to provider abrasion,” says Dr. Ahmed. “Health plans are interested in empowering providers with pre-claim self-monitoring portals and simplifying information access and engagement to remediate issues.”

Automating provider coding and billing education programs can drive greater ROI without adding workload to existing staff. “Most fraud detection systems are limited in the types of claims they can ingest and integrate,” said Subedi, Codoxo’s Director of Data Science. “But deploying a system that can ingest and analyze all claim types, including professional, facility, and pharmacy claims will create a holistic view across the payment spectrum.”

Earlier this year, Codoxo published a set of best practices for optimizing provider education and compliance, which also cites broadening claim type analysis beyond basic evaluation and management (E&M) codes and modifiers. Today, most solutions used to gain insight into provider billing and coding performance and then deliver education back to providers are limited in the type of codes that can be analyzed. Using an AI-based platform that analyzes complex codes and shares an expanded view of coding and billing patterns and performance with providers is foundational to true and impactful behavior change.

A final insight: always expect the unexpected

Fraudulent and erroneous healthcare claims cost the U.S. healthcare system between $68 billion and $230 billion annually. Not only is fraud significantly impacting health insurers’ bottom line, the burden of fraud is also impacting the cost of premiums and care.

The Coronavirus pandemic proves that dramatic and unpredictable healthcare challenges are just around the corner. “Healthcare organizations that embrace innovative, flexible and foolproof systems to help them proactively manage whatever comes their way will be a step ahead of their competition in years to come,” says Dr. Ahmed.


Codoxo Experts

The following Codoxo executives contributed to this trends report:

Dr. Musheer Ahmed, PhD is the CEO and Founder at Codoxo. Codoxo’s patented AI technology was developed as a part of his PhD dissertation at Georgia Institute of Technology. The JASON advisory group, a prestigious scientific advisory panel to the US government, leveraged Musheer’s doctoral research to reinforce major challenges within the emerging health data infrastructure in the United States.

Rena Bielinski, PharmD, AHFI is Vice President of Customer Success at Codoxo. Responsible for customer onboarding, satisfaction and success, Rena brings extensive experience that enables her to position customers for strategic growth in their fraud, waste and abuse endeavors. She has a Doctor of Pharmacy degree from the University of Illinois College of Pharmacy in Chicago (UIC) and she is an Accredited Healthcare Fraud Investigator (AHFI).

Rajesh Razdan is Vice President of Products for Codoxo. Rajesh collaborates with Codoxo’s data science team, executive leadership, and industry partners to find and create new ways to solve pressing cost containment challenges facing healthcare payer and agency customers. He holds a Bachelor’s in Computer Science and Engineering from the University of Mysore, India.

Prasoon Saurabh is Vice President of Engineering at Codoxo. Prasoon oversees development efforts for Codoxo’s Forensic AI Platform, which uses a patented algorithm to identify problems and suspicious behavior earlier than traditional techniques. He holds a BS in Computer Engineering from Amravati University and Kennesaw State University.

Saurav Subedi, PhD is Director of Data Science for Codoxo. He oversees product engineering, R&D and analytics efforts to build and enhance Codoxo’s Forensic AI platform to meet customer needs. He holds a Ph.D. and M.S. in Electrical Engineering from Villanova University and Missouri University of Science and Technology, respectively.