AI Solutions for Healthcare

CASE STUDY

Highmark Blue Cross Blue Shield

Highmark

Highmark Identifies Millions in New Active Cases With AI-Powered Provider Analysis from Codoxo

Highmark is one of the largest health plans in the United States, and the fourth largest overall Blue Cross Blue Shield-affiliated organization. With headquarters in Pittsburgh, PA, Highmark Inc. and its affiliates operate health insurance plans in Pennsylvania, Delaware, and West Virginia that serve more than 5.6 million members and hundreds of thousands of additional individuals through the BlueCard® program. Its mission is to create a remarkable health experience, freeing people to be their best. Highmark has always valued integrity, stewardship, and innovation.

Kurt Spear, Vice President of Financial Investigation and Provider Review at Highmark, leads a team of 65 professionals who are responsible for Highmark’s anti-fraud, waste and abuse (FWA) and post-pay payment integrity programs. Kurt’s team is dedicated to protecting Highmark’s customers and lowering the cost of healthcare by deploying comprehensive solutions that combat FWA. This pursuit of excellence led the FIPR team at Highmark to become one of the earliest adopters of advanced artificial intelligence solutions for post-pay provider analysis.

“Codoxo’s Forensic AI Platform is a game changer. AI is helping us identify, prevent, and stop potentially fraudulent activities earlier than ever.”

FIPR uses the Codoxo AI platform to help identify early patterns of suspect billing of medical services.   The team also uses rules-based systems to identify claims with known problems. But healthcare is always evolving and changing, and Kurt’s team knew they would need something more advanced to catch new problems before they could become big financial liabilities. The Codoxo Forensic AI Platform now analyzes all post-pay provider claims, with plans to extend the AI analysis to the pre-pay stage as well.

Highmark’s success with AI post-pay provider analysis so far:

  • Dedicated ideation team that includes nurses, certified coders, and ex-hospital revenue cycle administrators; review problems identified by Codoxo every week to prioritize the issues the FIPR team should look into
  • Codoxo AI has identified millions of dollars in cases the FIPR team is actively investigating
  • Will expand use of Codoxo’s Forensic AI Platform to the pre-pay stage to accelerate post-pay reviews and identify early signs of FWA

“Rules-based systems are good for things that don’t change often. Codoxo’s AI catches new problems that are evolving and may otherwise slip through the cracks of a rules-based system.”

FORENSIC AI PLATFORM

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Clinical Scope

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Audit Scope

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Network Scope

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Payment Scope

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Provider Scope

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Fraud Scope

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