Generative AI Session Demonstrates ClaimPilot’s Ability to Improve Payment Integrity Outcomes

A highlight of Codoxo’s Second Annual Customer Conference was the live session featuring our latest generative AI capabilities and product release, ClaimPilot, which was led by Rena Bielinski, VP of Customer Success, and Jesse Montgomery, VP of Analytics. Attendees joined to hear how Codoxo’s new generative AI solution can help organizations dramatically boost resource efficiency and cost savings by focusing on automating in-patient and facility claim audits.

Bielinski set the stage by spotlighting how healthcare costs are rising at an alarming rate, making it harder and harder for patients to afford the care they need and increasingly difficult for the medical industry to provide it at tolerable rates. In fact, national healthcare costs are projected to swell by 5.4% annually through 2031, ultimately accounting for nearly 20% of the total economy. 

Healthcare workforce burnout was also discussed, with 81% of clinicians in a recent survey reporting they feel overwhelmed and fatigued by tasks that divert their focus. Consistently, audience members polled during the session revealed that their biggest challenge is the labor required for manual review of complex claims from a workforce capacity standpoint.

The healthcare system is at a breaking point where it is imperative to find ways to bring down costs and address the growing demand for better patient and workforce experiences. Generative AI is poised to reinvigorate the U.S. healthcare system, and healthcare executives must pay attention to the promise of extreme advancements in automation, resource efficiencies, and cost reduction.

A Closer Look at ClaimPilot

ClaimPilot is Codoxo’s generative AI platform that conducts complex claim audits efficiently, automatically, and accurately. As the newest enhancement to our Unified Cost Containment Platform, ClaimPilot safely and securely integrates across Codoxo’s spectrum of payment integrity and fraud, waste, and abuse (FWA) solutions to deliver powerful capabilities that enable healthcare workers to focus on their highest priorities while generating substantial cost savings to healthcare organizations, estimated at $66 per member per year (PMPY) through their entire cost containment journey. 

The ClaimPilot live demonstration allowed attendees to see, firsthand and step-by-step, how the platform uses generative AI to drive exponential efficiencies in processing medical records and presents results to clinicians in an easily understood and actionable way. 

When a user logs into ClaimPilot, they see a dynamic “overview dashboard,” which serves as the central location for all claims data. The dashboard presents a comprehensive summary of all reviews that have been conducted and by whom, with appeals that are currently being processed. A “ready for review” section shows reviews that are pending or outstanding, and details the number of claims identified since the user was last in the system, which are categorized by type.

By clicking on “itemized bill review,” the user is presented with claims that are awaiting review. On the right side of the screen, ClaimPilot provides a summary of what is happening in each review category, including the quantity of claims and the outstanding values. When the user clicks on a claim they see line count, total charges, audit start date and, importantly, the “audit checklist.” This contains documentation that has been collected such as medical records and itemized bills. Impressively, ClaimPilot provides actionable recommendations about these claims and also for pending reviews – for example, if a case of upcoding has been triggered for review. And in all cases, users can dig deeper to actual claim records for further information. 

ClaimPilot models can be trained – in other words, ClaimPilot can adapt based on input from the person working with it. For example, our demo highlighted how within “itemized bill review,” ClaimPilot can help identify charges that may not be relevant for a particular review case, give the user the option to remove them from the audit, and prompt them to remove those same types of charges from outstanding and future audits, enabling the user to save valuable time. Once a claim has been vetted in this way, the user can indicate whether the remaining charges are to be approved or denied, code them accordingly, and then ClaimPilot will continue to process the claim. 

Clinical ClaimPilot Makes Clinician Jobs Easier

ClaimPilot’s first product application – Clinical ClaimPilot – is geared toward healthcare payers’ most dire need: automating in-patient and facility claim audits. 

Montgomery shared that in-patient claims are a huge cost-driver and can be highly complex, with many interrelated claims such as multiple hospital stays, multiple care teams, and barrages of tests that can be hard to cull together to efficiently review. Historically, complex claims could take clinicians, pharmacy techs, and reviewers days to weeks to complete, but Clinical ClaimPilot automates clinical claim audits, making the review process significantly shorter and producing consistent, accurate results. It eliminates claim dollar thresholds and enables up to 20 or more audits per clinician per day.  

A common concern when discussing the benefits of generative AI is whether generative AI will replace the jobs of investigators and clinicians. Montgomery addressed the concern, saying that the future lies with investigators and clinicians who adopt and use generative AI. He emphasized that the healthcare industry is at a crucial turning point, and opportunities with AI need to be taken very seriously, as it will empower teams to do more, be more efficient and more consistent and operate at the top of their license.  

(Read in greater detail about ClaimPilot and Clinical ClaimPilot benefits in our recent blog, “Generative AI for Payment Integrity: The Codoxo Vision and Promise” here). 

A Comprehensive, Secure AI Solution 

Codoxo has a mission to future proof payment integrity and will continue to leverage emerging AI-based technologies to drive improved customer outcomes and move to zero-touch payment integrity so investigators can operate at the top of their license. We are at the forefront of the industry, with unified platforms unparalleled by any other technology provider that enable customers to consolidate all of their data in one place. 

Using the Unified Cost Containment Platform, which now includes ClaimPilot’s generative AI technology, customers can get a singular view of what is happening across all vendors and providers, ingest and manage medical records and other relevant documentation, and store all of their data in their own virtual private cloud, which is certified by HITRUST for its high level of security.

ClaimPilot is the latest Codoxo innovation that alleviates resource constraints and frees clinicians and administrators of tasks AI can tackle more efficiently. But we will not stop there. We continue to invest in research and innovation to make healthcare even more cost-effective and efficient. 

Whether you are at the beginning of your AI journey, or further along, we are here to help. We guide healthcare payers, agencies and PBMs on their journey to decipher which AI technologies are best suited to holistically and measurably improve the full spectrum of payment integrity and FWA, from pre-claim submission and pre-pay to audit and post-pay. Our experts can engage at any level, leverage your existing data feeds, and have your first payment integrity product up and running in eight to 12 weeks.

To connect with a Codoxo team member to learn more about ClaimPilot and how our products can help your business, please contact us at info@codoxo.com.