AI Solutions for Healthcare

Effective Saturday, January 15, 2022, private healthcare insurers will be mandated to cover a maximum of eight at-home, over-the-counter tests per covered individual, per month. This new mandate for home testing coverage was enacted by Executive order under the March 2020 Families First Coronavirus Response Act (FFCRA).

Regardless of membership size, there is potential for significant exposure for unprepared healthcare insurers who lack robust detection and query tools to detect new fraud, waste and abuse (FWA) schemes created by the new mandate.

At an average reimbursement of up to $12 per test, costs for a family of four could total as much as $384 per month. As an example, when these reimbursements are scaled to a plan with two million members, the potential FWA exposure to the health plan could be in the tens of millions of dollars.

Currently, there is no procedure code for these at-home COVID tests, no requirement for a prescription or medical necessity, nor specific direction for benefit billing, making detection more difficult for the time being. This means health plans may see claims and duplicate claims billed across pharmacy, medical, and/or facility benefits leading to nearly impossible tracking at the member level of total at home tests reimbursed.

While the future of this mandate is uncertain, Codoxo is prepared today to support healthcare payers and the industry, to combat potential emerging schemes related to these tests and all COVID-related testing. Codoxo’s proprietary AI-detection software, Fraud Scope, can look across all claim types from disparate claims systems – pharmacy, medical, and dental, to analyze all claims at the member level, regardless of the code(s) used. Our AI solution can quickly identify duplicate claims, overlapping claims, detect services over the maximum allowed, and other patterns, regardless of who submitted the claim; pharmacy, DME provider, PCP, outpatient setting, etc. Codoxo can also detect overutilization/abuse of this benefit by a provider/member compared to their peers (similar geography, age group, demographics, etc.).

At Codoxo, we strive to help make healthcare more affordable and effective for all and use our industry-leading AI detection platform to make real change happen quickly.

How prepared are you? The time to act is now, let us help.

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