AI Solutions for Healthcare

–By Stacia Whelan | While working on his Ph.D. dissertation at the Georgia Institute of Technology, Musheer Ahmed envisioned a better way to apply artificial intelligence to the growing problem of fraud, waste and abuse in healthcare. His academic research was featured in top journals and presented at conferences around the world. In 2017, shortly after graduating, Dr. Ahmed founded Codoxo, where he serves as CEO and leads an organization of highly skilled healthcare executives, all driven to make healthcare more affordable and effective.

In this Q&A, Musheer Ahmed shares his insights on the exciting journey he has taken to building momentum and making a difference in healthcare.

What inspired or drove you to pursue your career path in healthcare artificial intelligence and ultimately, entrepreneurship?

When I started pursuing my Ph.D. in Computer Science at the Georgia Institute of Technology, I didn’t start with the intention of starting a company. At the time, the U.S. government was enforcing the adoption of electronic medical records. The goal was to make patient medical records more efficient and less costly.

But I knew there would be issues related to protecting sensitive patient information. During the course of my school work, I spent significant time researching methods to keep healthcare data from falling into the hands of bad actors. Because once healthcare data is stolen – which is inevitable – cybercriminals will monetize this information typically by engaging in fraudulent activities.

The federal government invited me to Washington D.C. to discuss how to secure patient data. Then I began attending industry conferences and speaking with health plans. I discovered a significant challenge: how to keep up with the evolving nature of fraud more proactively?  So, my Ph.D. focused on coming up with a sophisticated AI technology that worked really well. We patented it, and used it as the foundation of Codoxo’s AI-based platform.  


Codoxo has gained significant recognition as a trailblazer, first by being profiled by
Forbes, and then being named one of Georgia’s top 10 most innovative companies in 2021 by the Technology Association of Georgia. Why do you think Codoxo is catching such attention?

We’re helping to solve a problem that is only growing bigger. The financial losses due to FWA are estimated at up to 10% of total annual healthcare expenditures – or more than $300 billion each year – according to the National Health Care Anti-Fraud Association (NHCAA). This problem is expected to grow in magnitude. If health plans are struggling to cope today, how will they address this in the coming years as schemes become more extensive and sophisticated?  I believe our recognition and rapid growth is attributed to the fact that our AI technology is truly unique – we’re delivering solutions that are innovative and forward-thinking.

 

Codoxo recently announced it contributed to Highmark, Inc.’s reported savings of $220 million in 2020 by detecting and preventing suspicious activity. What do you credit to your success with healthcare payers such as Highmark?  

Health plans have primarily relied on traditional techniques such as rule-based systems to combat FWA due to the complexity of the healthcare system. Some plans and service providers have started exploring the use of supervised machine learning, which brings upon an entirely new set of challenges. However, such techniques focus on known and predicted schemes and cannot keep up with emerging FWA schemes in a timely manner. This causes health plans to bleed significant amounts prior to identification and prevention of them. Additionally, the false positive rates tend to be pretty high with existing products, which drains limited health plan resources.

Our artificial intelligence-driven platform gives commercial and government health plans the ability to quickly identify, investigate and take action on suspicious claims. Our platform contains various components such as detection, investigation, query, case management, and reporting that enable health plans to address FWA across various claim types such as professional, facility, and pharmacy. It can also identify collusion schemes across different entities that interact with health plans.

Ultimately, we help health plans identify new schemes more quickly, empowering them to take action faster than ever possible. This helps maximize savings at health plans both in prospective (pre-pay) and retrospective (post-pay) modes of detection. It also allows our clients to scale and identifies more opportunities with fewer resources. The platform also integrates results from any existing internal analytics and can help health insurers efficiently utilize their limited resources by prioritizing claims to ensure personnel time is spent on cases that will yield maximum savings.
 

Early in your journey, did you ever dream you would be making such an impact on the healthcare industry?

Once I learned the deeply pervasive nature of healthcare fraud and its impact on patient quality, my sheer focus became helping to solve this problem. As my research and technology developed, I began realizing how impactful our work could be.

When I was in graduate school, a prestigious panel of scientific researchers released an influential report on the biggest challenges facing America’s healthcare system. My Ph.D. work tried to address all of the concerns outlined: today, the healthcare industry is the most targeted industry by cybercriminals who try to steal data from any organization that stores them electronically. More than 1 in 3 Americans have their data stolen. Even my data is stolen and is on the black market – and frustratingly, there’s nothing I can do about it.  

Many of my early predictions from graduate school have come true. Fraud, waste and abuse has continued to increase; stolen patient and provider information are repurposed to file fictitious claims, and millions (now billions) of dollars are taken by thieves in schemes that will never stop evolving. Starting Codoxo wasn’t easy, but I was willing to put in the effort to see the true impact of our work.

 

With the competitive nature of the technology talent today, how are you attracting the skills needed to deliver upon your mission? And what do you look for when hiring new team members to support the Codoxo mission?

I couldn’t be more excited about our team. We’ve hired truly exceptional people at all levels who bring outstanding experience in technology, analytics, healthcare and insurance.  They are bright, curious and collaborative – and together, we’re innovating to help solve our client’s cost containment challenges. 

We’re looking to double our headcount in 2021. Some might say that our industry isn’t cutting-edge enough to attract top data scientists, product leaders, software engineers and coding analysts – we’re proving that wrong. Our work is meaningful and this resonates with job candidates.

Personally, it makes me feel great knowing that our team enjoys working at Codoxo because our culture is oriented around important values – our people, our clients, integrity, teamwork and innovation. These help guide and motivate us to stay focused on our mission.
 

What advice would you offer to other startup founders as they strive to move from concept to reality to thriving as Codoxo has done in its first five years?

I encourage entrepreneurs to align with mentors and peers who believe in their vision. You can’t go it alone. And as you bring your concept to life, keep innovating as you make progress by listening to customer feedback. For example, at Codoxo, we’re now expanding our capabilities to more broadly address payment integrity across the healthcare ecosystem. Continued insight from the field and growth in your team will bring you closer to achieving your mission.

 

To hear more insights from Dr. Ahmed, register here to attend an upcoming AHIP webinar, “Unified Cost Containment Approach & Next-Level Outcomes Using AI” (June 9).  For background about Codoxo, check out our explainer video.

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