In the first two installments of our Point Zero Payment Integrity series, we explored how AI-powered concept ideation and proactive provider reimbursement policy education are moving payment integrity to the earliest intervention point. Now, we turn to the third and final capability within the Point Zero suite—ongoing provider education to improve coding accuracy across the healthcare system and strengthen payment accuracy for health plans.
The Persistent Challenge: Improper Billing That Slips Through
Even with strong payment policies and upfront provider education, patterns of improper billing can still emerge over time. Healthcare providers may unknowingly adopt inaccurate billing practices or misinterpret evolving guidelines, leading to billing errors that pass unnoticed until claims hit prepay or postpay claims review. Those issues can include upcoding, medical necessity discrepancies, eligibility and claim submission mistakes, or CPT selection errors driven by complex pricing and documentation requirements.
When these errors are caught late, the results are predictable—and costly:
- Increased denials, resubmissions, and appeals that drain both provider and payer resources and raise administrative costs
- Provider abrasion caused by retrospective corrections and audits
- Delayed payments that strain provider cash flow
- Higher operational efficiency barriers for both sides due to rework and payment errors
Traditional payment integrity programs wait for these issues to surface in healthcare claims. By then, it’s too late—the cycle of waste, rework, and relationship strain has already begun for stakeholders across healthcare organizations.
A Continuous Feedback Loop for Accuracy
Codoxo’s Provider Scope takes a different approach. Instead of reacting after claims are created, Provider Scope uses AI with machine learning and data analytics to spot emerging billing and coding concerns at the source and streamline payment processes before adjudication.
Here’s how it works:
- Ongoing Provider Monitoring Driven by AI – Provider Scope continuously reviews billing patterns across both prepayment and postpayment claims processing. Its algorithms surface trends, outlier behavior, and potential non-compliance and FWA (fraud, waste, abuse) risks earlier and more accurately than manual fraud detection or one-time audits—while respecting HIPAA safeguards and CMS policy guidance for Medicare and Medicaid services.
- Targeted & Automated Education – Provider Scope enables health plans to set up and deploy automation for personalized education via each provider’s preferred channel—email, portal, or in-practice touchpoints. Content maps to medical records documentation, CPT/HCPCS coding, medical necessity, and real-time policy clarifications, reducing overpayments and improper payments before they occur.
- Peer-to-Peer Comparisons & Self-Service Tools – Providers access a co-branded portal to compare their coding against peers, review historical trends from claims data, and track improvements. These self-service workflows help teams correct discrepancies proactively and improve patient care without disruption.
- Follow-Up & Reinforcement – Education isn’t a one-time event. Provider Scope tracks engagement and schedules follow-up where needed, ensuring sustained behavior change and lasting accuracy gains. That includes guidance for corrective steps when patterns could otherwise lead to overpayments or downstream audits.
Why It Works: From Enforcement to Partnership
This ongoing model shifts the payer–provider dynamic from enforcement to enablement. Instead of being surprised by a denial or audit months after the fact, providers receive timely insights and clear steps to improve billing compliance—before a claim is even created. This prevents small issues from becoming systemic problems and reduces abrasion by avoiding punitive interventions aligned to CMS and Medicare policies.
Payers benefit from:
- Lower denial rates and fewer appeals
- Reduced audit volume (up to 30% reduction reported) and fewer payment errors
- Improved payment accuracy across lines of business, including Medicare and Medicaid services
Provider Education for Pre-Claim Accuracy
Continuous provider education completes the three essential capabilities of the Point Zero Payment Integrity model:
- AI-Powered Policy Development (Concept ClaimPilot) – Detect gaps before they create costly claim errors using advanced technologies and data analytics.
- Proactive Provider Reimbursement Policy Education (Provider Scope pre-policy activation) – Deliver targeted guidance before new policies go live to streamline implementation.
- Ongoing Provider Education for Coding Accuracy (Provider Scope continuous coding improvement) – Sustain improvement with AI-driven monitoring, automation, and monthly education to reduce inefficiencies and healthcare cost burdens tied to FWA and healthcare fraud.
Learn More at the Upcoming Webinar
Provider Scope: Ongoing Education – Continuous Pre-Claim Coding Accuracy
Live: August 28 | 3:30 PM EST or on-demand
Join us to see firsthand how AI analyzes each provider’s billing patterns to deploy monthly education programs through preferred channels. Learn about peer-to-peer coding comparisons, self-service performance reporting, and real-time tips that help providers correct patterns before submitting inaccurate claims—and before adjudication and appeals escalate. We will also highlight a brief case study illustrating how automation closed gaps and reduced overpayments.