AI Solutions for Healthcare

During last month’s Codoxo Customer Conference, clients deepened their understanding of Codoxo’s full breadth of AI-based cost-containment solutions designed to help make healthcare more affordable and effective. There was an extra emphasis, however, placed on delivering training, education, and importantly, sharing success stories from across the client base of Codoxo’s flagship product, Fraud Scope.

Fraud Scope is used every day by our health plan and agency clients to help identify, prevent, and mitigate the risks of fraud, waste, and abuse and is the only platform on the market today doing so with the most accurate and effective AI. Our clients shared use cases and significant outcomes with our customer community, which included their stories of adopting AI-based FWA solutions and the ways in which the platform is helping their SIUs quickly identify emerging trends and outlier behaviors.

The sharing of use cases enabled our customer community of FWA and PI experts to learn new best practices, tips, and strategies from their peers at other health plans and agencies, which will help them improve SIU operations and enhance their own cost containment outcomes.

The major success story themes centered around:

      • Identifying
      • Analyzing
      • Acting
Identifying Potential FWA with Fraud Scope

During the customer roundtable session, a health plan based in the northeast shared how they were able to find fraud when Fraud Scope alerted them that a practitioner was frequently using an unlikely procedure code. After requesting medical records, they learned that the provider was using the unlikely procedure code to represent infrared therapy, which is considered experimental and excluded under the plan’s policies. The provider appealed the health plan’s demand for recovery citing that the medical records did not support the services being billed. Upon appeal, the health plan upheld their decision, citing misuse of the code and the provider is on a repayment plan to the tune of nearly $200,000.

The same health plan also shared a case of a provider who made the mistake of interchanging the code for a 15-minute increment treatment with an hour-long billing treatment. Fraud Scope detected that the provider billed the health plan for 226 hours of treatment for one patient in a one-week period, which is impossible. The provider agreed to take back the bills and correctly re-submit them, which saved the health plan approximately $43,000. This mistake went unnoticed until the plan processed a single query in the Fraud Scope platform.

Another health plan shared how they utilized the query tool to identify combinations of procedures that should not appear more than once per day. With only a few criteria selections and entries, the query tool identified scenarios where two different providers received payment for the same code, same patient and same day, pointing to potential overlapping services. The query tool results in combination with the duplicates detector by the same provider results provided the plan with more opportunities for recoveries.

Analyzing problems in real time

A health plan customer presenter shared their experience using Fraud Scope and how they were blown away by how well the AI technology not only identifies problems, but also quickly analyzes them. Because the healthcare industry is always evolving and changing, it’s important to have a solution that is advanced enough to keep up with the always-changing trends. “Fraud Scope has been a game changer for us in identifying, preventing, and stopping potentially fraudulent activities earlier than ever,” the large health plan client indicated.

Codoxo’s Fraud Scope solution can ingest and analyze all professional, facility, pharmaceutical, behavioral, dental, and workers compensation claims. By providing in-depth analysis of each claim, SIUs can focus on the ones that really matter, effectively and efficiently, as opposed to trying to pull information from various sources and analyze them manually.

The solution currently presents FWA analytics as provider reports, surfaces high risk targets, and provides numerous peer comparisons across all providers in the same specialty. This allows for a group of analysts or investigators who are focusing on a certain specialty the ability to view all the providers who have been identified within those specialties.

Acting to contain healthcare costs

A large health plan shared a use case where a provider was billing telehealth services, while at the same time reporting the location of service as in-office appointments, which was a big red flag. Additionally, Fraud Scope alerted them that the provider was also billing for transitional care management (TCM) abnormally.

Upon further investigation, the health plan found that the provider did not have any patients that indicated needing TCM. Based on the findings, the health plan assigned the case to a senior investigator who conducted an audit and placed the provider on an immediate prepay flag, requiring the provider to submit office notes for the codes used. The office notes did not match up with the codes used, so the health plan will now be receiving reimbursement from the provider for the misused codes. The early detection by Fraud Scope allowed the health plan to identify the FWA quickly and take immediate action.

Fraud Scope enables SIUs to act quickly by bringing together all the information related to a suspected FWA issue, including full notes and event history, related claims tracking, document repository, financial impact, user assignments, and case logs.

Fraud Scope success: By the numbers

When it comes to Fraud Scope savings, the numbers speak for themselves. In only 12 weeks of using Fraud Scope, a state Medicaid agency was able to realize a 1,500% return on investment, more than $4 million in back billing opportunity, nearly $7 million in total risk exposure, and an overall estimated recovery of more than $1.7 million.

A large national health plan shared that when they used Fraud Scope, they immediately noticed large dollar amounts for paid exposure and a significant number of high-risk scores. To ensure they were getting the most out of the product, the team compared findings against leads they identified through other sources. The result? Fraud Scope detected nearly all the leads, capturing approximately 97% of exposures. The solution also assigned a high-risk score of 40+ to every provider with $1 million or more in potential exposure, allowing the client to prioritize the highest exposures first — a critical step for payers to prioritize resources when struggling with the high false-positive rates of most AI-based FWA solutions.

These are just some of the success stories that our customers shared during the Codoxo Customer Conference. Read more case studies to learn how Fraud Scope and other products are helping some of the largest U.S. plans and agencies identify FWA.

To speak to a Codoxo team member about the Fraud Scope platform, please contact us at