In the second installment of our Point Zero Payment Integrity product webinar series, we shift the focus from identifying payment policy gaps to medical policy activation—specifically, how Codoxo’s Provider Scope solution helps payers communicate changes before they become provider compliance problems.

While Concept ClaimPilot empowers payment integrity teams to identify gaps in their payment integrity concepts, Provider Scope then ensures new policies land effectively with the right health care providers, at the right time, through the right channels. It’s the critical second step in moving intervention further upstream in the claim lifecycle, and a powerful way to reduce provider abrasion and increase trust.

The Challenge: Medical Policy Changes Without Context

Health care providers today face a relentless stream of medical policy updates from a multitude of health plans, including Medicare, Medicaid services, and health insurance payers. Unfortunately, most receive these changes in the form of generic bulletins, buried provider portal notifications, or after-the-fact denials. The result is frustration, increased denials, and growing abrasion between payers and providers.

For payers, this often triggers:

• An increase in appeals and reconsiderations resulting in increased admin costs
  
• Higher call center volume from providers seeking additional information
  
• Delays in medical policy rollout due to anticipated non-compliance concerns
  
• Denials that could have been avoided with targeted provider education and a proactive compliance program
  

The truth is, many health care professionals aren’t resistant to compliance. They just lack relevant, timely insight into how changes will affect their billing, covered services, and reimbursement, along with clarity on eligibility, enrollment, and medical necessity requirements for beneficiaries.

The Solution: Provider Scope’s Policy Education

Provider Scope delivers AI-powered, pre-policy provider education and go-live support—a smarter, more collaborative way to manage reimbursement and health care services changes in alignment with federal laws, state law, HIPAA regulations, and U.S. Department of Health guidance.

Here’s how it works:

• AI identifies impacted providers based on 12 months of historical provider billing and medical record and claims data
  
• Codoxo shares policy-specific financial impact with providers (e.g., number of affected claims, allowed dollar amount, changes to fee schedule)
  
• Notifications are sent through preferred channels—email, mail, in-person meetings, or integrated into existing health care programs and provider portals via SSO
  
• Providers gain clear visibility into the impact of new/updated policy before go-live, with time to adjust coding and billing practices in compliance with CMS, Medicare, and Medicaid services guidelines
  
• Codoxo monitors provider behavior change, engagement, and provides follow-up if needed, including guidance on corrective action, attestation, and credentialing steps
  

The experience is consolidated in a Provider Portal, where users can:

• Review impact summaries
  
• Access affected CPT/HCPCS codes for services provided
  
• See bulletin history and related education program materials
  
• Click through to linked medical policy documents
  

This personalized, data-backed outreach helps health care providers understand exactly how medical policy changes affect them with no guesswork or after-the-fact confusion. It also reduces risks of overpayments, sanctions, or health care fraud investigations by the Office of Inspector General (OIG) or the Department of Health and Human Services (HHS). By clarifying requirements for licensure, accreditation, and referral protocols, Provider Scope helps ensure smooth transitions in medical care delivery that align with both payer and public health priorities.

Why It Works: Trust Through Targeted Provider Education

When providers know what to expect, and why a change matters, they are far more likely to maintain provider compliance. They’re also less likely to file appeals or escalate denials that could have been avoided with upfront provider education. The model also supports patient care quality, ensuring medical services and medical equipment are ordered and delivered appropriately within the approved service area.

Payers benefit through:

• Lower administrative burden from fewer denials and appeals
  
• Stronger adoption of medical policies across diverse provider groups, including nursing facility and registered nurse staff
  
• Faster rollout of new edits and rules with less friction
  
• Reduced confusion over copayments, prescription drug coverage, and family member eligibility
  
• A better provider experience, rooted in partnership—not enforcement
  

It’s a model that reflects the spirit of Point Zero Payment Integrity: prevent, don’t just correct. Partner, don’t police.

Real-World Impact

Payers using Provider Scope have reported:

• Reduction in policy-related appeals and disputes
  
• Decreased provider abrasion during rollouts
  
• Increased provider adoption of compliant billing behavior
  
• Smoother, faster transitions for sensitive or high-risk medical policy changes, including mental health, outpatient, and inpatient care policies under managed care and fee-for-service models, with clear time frame expectations for policy adoption
  

Learn More at the Upcoming Webinar

Provider Scope: Proactive Pre-Policy Activation
Live: August 21 | 2:30 PM EST or on-demand

Join us live as we explore how Codoxo’s AI identifies impacted health care providers and delivers medical policy education before claims are created. Learn how real-time financial impact analysis and targeted communication drive smoother transitions, higher provider compliance, and improved alignment with gov and department of health and human services guidelines.

Register now for the webinar
Revisit Blog 1: Concept ClaimPilot