Harvard Pilgrim Healthcare

Harvard Pilgrim Health Care Embraces Artificial Intelligence From Codoxo To Detect FWA Issues

Harvard Pilgrim Health Care is a leading not-for-profit health services company serving more than 3 million members in Connecticut, Maine, Massachusetts, New Hampshire and beyond. Harvard Pilgrim strives for quality in everything they do. With a constant focus on always doing the right thing and ensuring members get the highest quality care, it is no surprise that Harvard Pilgrim embraces leading-edge technologies and takes every effort to root out fraud, waste and abuse.

Brian Robinson, Director of Harvard Pilgrim’s Special Investigations Units, wasn’t satisfied with the status quo. His team had been using a traditional rules-based fraud detection system for years but had grown frustrated by the layers upon layers of false positives it identified.

While looking for a new solution Brian’s team started building their own system internally. He luckily had a data warehousing genius on his team who was able to build all the reports they needed to tie them over while they explored the new generation of artificial intelligence fraud detection solutions. Harvard Pilgrim Healthcare ultimately selected Codoxo’s AI fraud detection solution to run alongside their internal solution and use Codoxo to identify claims and provider behavior that doesn’t look normal.

Harvard Pilgrim Healthcare’s success with AI fraud detection so far:

• Codoxo’s AI identifies problematic providers based on their coding practices
• Quality of fraud leads from AI far surpasses the quality of leads from their old rules-based system
• Codoxo’s AI identifies provider behavior that is outside the norm
• AI analysis and detection helps ensure that new fraud schemes don’t sneak up on the team

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“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.”