How AI-Driven Provider Education and Portal Could Save Payers Millions

Codoxo’s Provider Scope has saved one health plan $5 PMPY in just a few short months. For mid-size health plans, this could translate to $2 million to $3.5 million in cost avoidance a year.

Provider education, while critical to ensuring accurate payment integrity and reducing fraud, waste and abuse (FWA), doesn’t always get the attention it deserves. The process of educating providers on coding and billing best practices to improve claim integrity is often handled reactively, with SIU and PI teams stepping in when outlier behavior is identified. This traditional approach eats into limited time and resources and can strain the payer-provider dynamic.

AI-based provider education is changing that by empowering healthcare payers to revamp their pre-claim submission processes to fuel more holistic payment integrity. Codoxo’s Provider Scope, for example, automates workflows and identifies outlier cases earlier in the process, leading to significant cost savings.

In fact, one health plan recently realized savings of $5 per member per year (PMPY) in just a few short months by leveraging Codoxo’s AI-based provider education platform and provider portal. For a mid-size health plan with 500,000 members, that could translate into $2 million to $3.5 million in cost avoidance a year.

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 success story to leaders in payment integrity and revenue cycle management to discuss how AI and generative AI are driving improved cost containment. Their presentation, “AI-Driven Provider Education Saving Millions for Payers,” outlined how AI-powered solutions such as Provider Scope and its provider portal are shifting the industry left toward zero-touch payment integrity.

A Provider Scope Success Story

Designed for provider network and payment teams, Provider Scope is a self-monitoring and communication portal that makes it easy to compare claims and coding practices to peers. The solution identifies outlier behavior and proactively engages billing teams to improve claim integrity and accuracy.

In the case highlighted at HPRI, a health plan selected Provider Scope to supplement their current FWA platform, Fraud Scope, Codoxo’s flagship AI product. By investing in Provider Scope, the health plan aimed to catch and fix errant billing behavior upstream in the payment process to drive next-level outcomes. Their goals included leveraging sophisticated AI to achieve pre-claim savings, cost avoidance, and improved billing and payment accuracy. Enhancing provider partnerships was another priority. 

After a short implementation timeframe – about 14 weeks – the health plan used Provider Scope to select all of Codoxo’s existing coding themes. By doing so, the health plan identified and integrated the top 40% to 50% of egregious providers into their provider portal.

This process empowered the health plan’s provider network with new levels of transparency and insight. By offering never-before-seen coding and billing performance reporting, the health plan drove rapid behavior change and significant savings – all with little to no provider abrasion. 

The health plan’s payment integrity unit is now able to quickly identify providers who may benefit from further education based on their outlier coding and billing patterns. Not only was $5 PMPY savings realized in just a few months by leveraging Codoxo’s AI-based provider education, another remarkable impact was realized: 30% of providers started using Provider Scope’s self-monitoring portal after receiving just one education letter, allowing them to easily see how their coding practices compare to their peers and make adjustments.

The Benefit of a Proactive Approach

There’s no question – AI-based provider education is key to a healthcare cost containment industry that’s embracing transformative innovation. By comprehensively analyzing all codes for education, Provider Scope can identify once undetectable coding issues and complex code sets. It also gives both payers and providers increased visibility into coding methodologies, a huge advantage.

Health plans seeking advanced payment integrity programs should adopt coding and billing education tools that offer more transparency and accountability throughout the payment lifecycle, leading to less friction between payer and provider. Proactively educating providers maximizes accuracy, making it possible to avoid the costly, burdensome and abrasive professional and facility claim audits. Providers can clearly see how their post-pay claims and coding practices compare to professionals in the same specialties and can self-correct to improve their coding accuracy.

Health plans like the example above are leveraging AI to realize significant pre-pay cost avoidance, and saving millions of dollars every year.  Are you ready to join them?

Innovating for Better Healthcare 

As the payment integrity industry continues to shift left through pre-claim submission efforts, executives are looking for AI-driven tools to maximize coding accuracy and increase savings.

Codoxo is focused on making healthcare more affordable and effective for everyone. With our portfolio of AI-driven solutions and services, we’re proudly leading the industry’s transformation toward zero-touch payment integrity – with AI-powered provider education as a critical piece of this vision.