AI Solutions for Healthcare

During our recent second annual Codoxo Customer Conference, dozens of attendees came together virtually to network, learn, and share best practices for reducing fraud, waste, and abuse and ensuring payment integrity.

One of our most popular sessions was the Fraud Scope Customer Roundtable. Four healthcare payer customers teamed with Codoxo fraud analysts to present real-world stories showcasing Fraud Scope’s superior identification of outlier behaviors for measurably improved cost savings. 

Fraud Scope is Codoxo’s groundbreaking flagship product that helps health plans, healthcare agencies and PBM teams stay ahead of evolving fraud threats by identifying and flagging emerging schemes for rapid review and intervention faster and better than similar solutions. Its advanced and proprietary AI technology quickly and accurately detects fraud, waste and abuse while providing SIU and PI teams with fully automated case and lead workflows.

In addition to sharing tips on effectively using Fraud Scope for lead detection, actions, and outcomes, our customers highlighted Fraud Scope’s remarkable ability to identify billing discrepancies that drive faster and more accurate payment recoveries. Across our panel of just four customers – each sharing a single case – savings amounted to $367,000!

Identifying Duplicate Claims

One health plan shared how their team uses Fraud Scope to identify and sort through duplicate claims and recoup significant funds. 

Typically, duplicate claims are the result of clerical errors or claim resubmissions with the original claim not being canceled. This health plan used the “schemes detection” feature of Fraud Scope to look for cases that had high dollar amounts but a low number of claims. 

In this case, they identified a manageable case with a nearly $20,000 price tag with four claims. Through subsequent research, they discovered there was only one provider, but two dates of service just a month apart. Further digging revealed that a corrected claim with a slightly different dollar amount was submitted, however the duplicate claim had not been caught. Impressively, the correction resulted in a $40,000 recoupment from the provider. 

Uncovering Problems with Paper Claims   

Another health plan with a newly-established SIU program and  limited resources shared how they partnered with Codoxo to identify low-hanging fruit surrounding provider billing errors and/or fraud. 

In this case, Fraud Scope and the Codoxo team assisted  the plan with discovering that in just a one-month period they had paid a single emergency room provider for 10 units of service when only one was allowed – resulting in a payment 10x what it should have been. Further investigation uncovered nearly 100 such claims had been filed. As a result, the health plan recovered  nearly $130,000.

Catching Misused Medical Kits

Another health plan recounted how it used Fraud Scope to recover overpayments from providers who were misusing autonomic nervous system (ANS) testing kits and billing them to the health plan. These are specialized tests that should be given in a controlled setting, with results reviewed by a neurologist. 

Via Fraud Scope’s detection showing high utilization of these kits, they did further queries in  Fraud Scope to search for relevant CPT codes to see how the tests were being performed. They discovered four family physicians were improperly using the kits for mobile testing, and in turn, generated well over $100,000 in recovery requests. Subsequently, the team delivered education to their providers on proper use of the kits to avoid future incorrect payments. 

Preventing Over-Billing

Another healthcare payer shared how their team’s use of Fraud Scope enabled them to catch excessive time-based billing by a behavioral health provider. The provider had been on the plan’s radar for a history of over-billing time; over the past two years, the provider had often billed 10 hours a day – and sometimes up to an impossible 50 hours a day. The team looked at a four-day snapshot of the medical records and found he had been billing hours for himself serving in a supervisory role for therapists significantly beyond the supervision limits set forth by the state. Ultimately, the team recovered payments and put the provider on a pre-payment review. Impressively, the team has prevented nearly $80,000 in overpayments  since August. 

These are just a few of the success stories we heard during the 2023 Codoxo Customer Conference where Fraud Scope and our other AI products are being used to catch fraud, waste and abuse and recover or prevent improper payments.  We’re excited to share many more!  Be sure to stay tuned. 

To connect with a Codoxo team member to learn how Fraud Scope or other products can help your business, please contact us at