AI Solutions for Healthcare

Fraud Scope

Automatically and accurately detect existing and emerging fraud schemes with an AI-assisted solution

Fraud Scope automatically detects new and emerging fraud schemes, streamlines the collection of evidence chains, and gives SIU teams integrated case workflow for the FWA investigations you choose to pursue.

Our AI-assisted fraud, waste and abuse detection solution is popular with SIU teams and those individuals focused on reducing FWA costs at major healthcare companies and agencies across North America. It includes:

Forensic AI Platform detects problems earlier

and can quickly identify new, emerging, and existing fraud schemes with very low false positives

Clear scheme explanations

make it easy for everyone using the Fraud Scope application to quickly get up to speed on the newly identified problem, or see the full history of a well-known scheme

Prioritization of suspicious claims

based on the Codoxo Claims Risk Score and dollar amounts to maximize savings

Evidence chains

are automatically gathered by the Forensic AI Platform, clearly presented to SIU teams, and users have the ability to deep dive and validate the AI findings if they choose to do so

All-in-one case management

brings 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. Each client may customize the Fraud Scope case template for your specific fields and process

Integrated workflow

supports collaboration and information sharing across the organization

Smarter ad-hoc investigations

with easy-to-use queries and self-service reports that are easy to customize – without any help from IT

Complements existing analysis techniques

and can integrate data from your existing intelligence feeds

Patent-pending AI analyzes claims

and gives you unique behavioral insights into every provider, facility, pharmacy and member involved

New risk alerts and active watchlists

flag claims from providers, facilities, pharmacies or dental practices suspected of FWA activities

Provider Integrity Score

indicates whether or not providers are associated with any new or existing fraud schemes, or have recent coding practices that fall outside the norm of their peers. Fraud Scope gives SIU teams detailed explanations for each provider integrity score

AI analyzes
all claim types

Codoxo can ingest and analyze all professional, facility, pharmaceutical, behavioral, dental, and workers comp claims.

AI analyzes
all CODES

Our patented AI technology has the ability to identify issues and opportunities that may arise from complex claims and codes in addition to the standard ones which helps discover a wider range of existing and emerging problems.

Fraud Scope is built on our Forensic AI Platform and a part of the Codoxo Healthcare Integrity Suite

Our AI engine analyzes your claims data, detects practices that intentionally or unintentionally waste money, and builds connections across your data to provide actionable insights.

Codoxo_ProductStackDiagram_Fraudscope

Saving millions at world-class insurance companies and healthcare agencies including:

State Medicaid Agency

2+ million recipients

Southeast Blue Plan

3+ million members

Midwest Blue Plan

2.9 million members

Pacific Health Plan

700K+ members

“Just being able to identify the behavior that is outside the norm is massive for us. Codoxo’s AI detection engine helps us ensure new fraud schemes don’t sneak up on us.”
Highmark

– Brian Robinson, Director Special Investigations Unit

Ready to get started?

Talk with a sales rep to get a demo of Codoxo and learn more.

FORENSIC AI PLATFORM

Our Forensic AI Engine analyzes your data, detects problems, and builds connections across your data to provide actionable insights

Insight Scope

For everyone across the health plan

Clinical Scope

For clinical teams

Network Scope

For network teams

Payment Scope

For payment integrity teams

Provider Scope

For network and payment teams

Fraud Scope

For SIU teams

SERVICES

We provide a full range of professional services, from data migration and ongoing customer success through flexible virtual SIU options.

Fraudscope is now Codoxo. LEARN MORE >