Codoxo’s Provider Scope has saved one health plan $5 PMPY in just a few short months. For mid-size healthcare payers, this could translate to $2 million to $3.5 million in cost savings and overpayment avoidance annually.
Provider education, while critical to ensuring accurate payment integrity and reducing fraud, waste and abuse (FWA), doesn’t always get the attention it deserves. Educating healthcare providers on billing practices, ICD-10, CPT, and HCPCS coding to improve claims review and payment accuracy is often handled reactively—typically triggered by billing errors, claim denials, or after costly underpayments and improper payments have already occurred. This approach not only drains resources, but also increases administrative burden and friction between payers and provider networks.
Why AI Is Changing the Equation
AI-based provider education is reshaping this paradigm by empowering healthcare organizations to revamp prepayment and claims submission processes and optimize their end-to-end payment integrity programs. Codoxo’s Provider Scope, for example, automates workflows, enables real-time insights, and flags claims data anomalies much earlier in the adjudication cycle, leading to material cost savings and increased operational efficiency.
In fact, one health plan recently realized savings of $5 PMPY by leveraging Codoxo’s AI-based provider education platform and self-service portal. For a mid-size payer with 500,000 members, that translates into $2–3.5 million in annual cost avoidance.
Presented at the HPRI Congress
During the Healthcare Payment & Revenue Integrity (HPRI) Congress South in February, Codoxo’s Jesse Montgomery (VP of Analytics) and Rena Bielinski (VP of Customer Success) presented a powerful success story to CMS-aligned leaders in reimbursement, claims processing, and revenue cycle. Their presentation, “AI-Driven Provider Education Saving Millions for Payers,” outlined how solutions like Provider Scope are driving a leftward shift toward zero-touch payment integrity and helping payers streamline the review process.
A Provider Scope Success Story
Designed for payment integrity units, provider billing teams, and health plan operations, Provider Scope is a self-monitoring and communication portal that compares claims, billing, and coding performance across true peer groups. The tool detects outlier behavior, helps optimize coding accuracy, and proactively engages medical record and billing teams—without disrupting healthcare services.
In the HPRI case study, a major healthcare payer adopted Provider Scope to complement their existing FWA platform, Fraud Scope. Their aim: catch and correct errant billing errors early in the payment process, reduce downstream issues like claim denials, and ensure greater payment accuracy and accountability.
After a rapid 14-week implementation, the health plan onboarded Codoxo’s top coding themes and identified the top 40–50% of egregious billing patterns. These healthcare providers were invited to the portal, where they gained transparent access to their own claims data and comparative data analytics insights.
Measurable Impact & Behavioral Change
By providing access to real-time, AI-driven reporting, the health plan achieved quick wins:
- Realized $5 PMPY in pre-pay cost savings
- 30% of providers engaged with the portal after receiving just one education letter
- Achieved behavior change with minimal provider abrasion
The AI-generated insights helped healthcare providers see how their billing practices compared across specialties and enabled them to self-correct using portal-based automation and self-service monitoring—without the need for intrusive claims audits.
The Benefit of a Proactive Approach
Artificial intelligence and machine learning unlock a more proactive, intelligent model of healthcare payment. Provider Scope analyzes complex codes, identifies historically missed coding issues, and provides eligibility-aware, specialty-specific benchmarks.
By embracing these innovations, health plans and insurance companies gain transparency across the full claims lifecycle, while reducing friction in prior authorization, claim submission, and pricing accuracy.
The result:
- Fewer improper payments
- Reduced need for post-pay audits
- Greater accountability throughout the healthcare system
Innovating for Better Healthcare
As the payment integrity landscape shifts left through prepayment initiatives, more executives are turning to AI-based tools to optimize claims review and improve the value of their integrity programs.
Codoxo is leading that transformation. Our end-to-end portfolio of AI-powered solutions—including Provider Scope, Fraud Scope, and analytics services—is purpose-built to make healthcare more affordable, more compliant, and more efficient.
We believe the future of payment integrity solutions lies in collaboration, early detection, and smart automation—all supported by transparent, AI-powered review processes.
Join the Movement
Want to learn more about how Codoxo is helping payers improve payment integrity and achieve scalable healthcare cost containment?
Check out our latest webinar or contact us at info@codoxo.com to schedule a personalized demo.