Rethinking Payment Integrity at the Concept Level

In the face of rising healthcare claims complexity, mounting healthcare payer administrative costs, challenges around payment accuracy, and strained provider relationships, payment integrity professionals are increasingly asking a different kind of question about claim payments: What if we didn’t wait until a claim was submitted to intervene?

Historically, healthcare payment integrity solutions have focused claim review downstream at prepayment and postpayment—denying or recovering improper payments to recover financial losses. While necessary, these claim processing methods have real costs—and they’re resource-intensive, reactive, and often lead to provider abrasion. Compliance issues due to policy misalignment, inconsistent edits, and unclear communication only make things worse.

But what if coding errors could be anticipated and prevented before a claim is even created?

That’s the shift behind Point Zero Payment Integrity—a model that moves intervention upstream to drive greater cost savings. And the first step in that journey is rethinking how reimbursement concepts are developed in the first place.

This blog explores how forward-thinking payment integrity teams are moving “left” in the payment lifecycle by adopting advanced technology like Concept ClaimPilot, Codoxo’s AI-powered data analytics platform for rapid risk spotting for payment integrity teams through generative AI-powered creation, testing, and refinement of healthcare claims payment methods.  

What is Concept ClaimPilot?

Concept ClaimPilot is part of Codoxo’s ClaimPilot platform, a suite of generative artificial intelligence tools for payment integrity processes. While the broader platform supports prepay and postpay optimization, Concept ClaimPilot is the only solution built for the Point Zero phase—before claims are created.

Powered by Codoxo’s patented Forensic AI Engine, Concept ClaimPilot combines data mining and real-world analytics with a no-code interface to surface policy gaps, simulate edits, and align with provider behavior.

It enables policy, clinical, and SIU teams to:

• Identify policy gaps or inefficiencies based on emerging risk patterns
• Rapidly test and simulate new edits before deployment without code or technical lift
• Leverage data mining to analyze provider billing behavior and detect misalignments in policy application
• Iterate on reimbursement policies using real-world data and AI, not spreadsheets
• Get to deployment faster—with no code and no IT dependency

Instead of catching billing errors after submission, Concept ClaimPilot empowers payers to design smarter policies from the start, reducing abrasion, rework, and waste.

Empowering Providers Through Clarity, Not Correction

For healthcare providers, one of the greatest challenges is staying current with frequent policy changes across multiple payers. Updates are often delivered in large batches or via generic portals, with little direction on which changes matter most. As a result, providers may only learn of policy changes after claims submission, when they trigger denials—fueling frustration and inefficiencies. Concept ClaimPilot changes that, with better provider contract and medical policy compliance.

By enabling payers to simulate and refine edits early in the process, teams can:

• Identify which healthcare providers are most likely to be impacted by policy updates
• Spot unintended consequences of a proposed policy
• Providing insights into financial impact and coding adjustments
• Flag areas where education or clarification may be needed and send targeted guidance through preferred communication channels
• Build reimbursement edits that reflect how providers actually code, not just how they should

This early visibility improves payer-provider partnerships, helping payers avoid issuing edits that are clinically misaligned or operationally disruptive. Providers, in turn, get the context they need upfront around bill review, rather than learning about a change through a denial or audit. This transparency reduces administrative burdens, builds trust, and encourages first-time accuracy.

Potential Use Cases: From Manual to Model-Driven

Use Case: Policy Gap Discovery

A PI analyst at a large health plan notices high variability in how providers bill for moderate sedation. Instead of exporting reports and manually reviewing denied claims, they apply Concept ClaimPilot’s data mining capabilities to simulate how current edits handle the CPT codes in question and discover inconsistencies in reimbursement logic. A revised edit is drafted, tested, and shared with compliance, all within a day and without developer involvement.

Outcome: Cleaner edits, fewer downstream denials, and a smoother provider rollout.

Real-World Outcomes

Health plans using Concept ClaimPilot report:

• Faster policy development cycles, often with no IT lift
• Reduced abrasion through data-driven alignment and clearer communications
• Fewer manual iterations to validate edits
• Use of advanced data mining uncovers overlooked vulnerabilities in reimbursement logic
• Earlier detection of problematic concepts

This is a smarter, more sustainable model built not just to catch payment errors, but to prevent them.

Ready to shift your concept workflow efforts pre-claim? Learn how Point Zero Payment Integrity is transforming healthcare cost containment by engaging providers before claims are created at pointzeropaymentintegrity.codoxo.com. 

Learn More at the Point Zero Micro Webinar Series 

Interested in learning more about Concept ClaimPilot? Join us for our upcoming Point Zero Payment Integrity Webinar Series.

Concept ClaimPilot: Building Smarter Policies Before Claims Enter Your System
Date: Thursday, August 14, 2025
Time: 2:00 PM Eastern Daylight Time
Duration: 30 minutes

Focus: AI-powered concept ideation and policy development

Learn how Generative AI analyzes claims data to rapidly identify payment gaps and build reimbursement policy concepts that can be deployed across your entire payment spectrum—from provider education through postpay recovery. This no-code approach enables quick policy development before problematic claims enter your system.

Learn More and Register

Other Resources:
Explore Concept ClaimPilot
See how it works

Revisit the Point Zero vision
Read our foundational blog