CASE STUDY
National Health Plan Uncovers Millions
National Health Plan Uncovers Millions in Previously Undetected Payment Integrity Opportunities with Codoxo’s AI-Powered Data Mining Services
Codoxo analyzed multiple years of datasets across categories, representing 37M claims, 108M claim lines, and $20B+ in paid claims.
Background
A leading national health plan had built a mature payment integrity program supported by experienced internal teams, established workflows, and multiple vendor partners. While those efforts consistently identified and recovered overpayments, leadership recognized that even sophisticated programs can develop blind spots over time.
Solution
The evaluation included 23 payment integrity concepts spanning four complementary areas: AIgenerated fraud leads, cross-data analysis, AI-driven payment integrity concepts, and traditional rules-based validation. This multi-layered approach enabled the health plan to evaluate both known payment integrity risks and emerging opportunities that had not previously been investigated. In 60 days, the assessment uncovered foundational payment integrity issues that had escaped existing processes, previously unidentified anomalies surfaced through AI, reimbursement policy enhancement opportunities, and additional concepts identified for future evaluation.
The results were impressive:
• $60M+ in identified payment integrity exposure
• $30M+ in opportunities validated for additional review and potential recovery
• Multiple previously unidentified payment integrity concepts identified
By combining advanced AI with experienced payment integrity experts, Codoxo uncovered significant opportunities that existing approaches had not identified, and performed root cause analysis to reveal the operational and reimbursement policy factors contributing to those findings.
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