Every year, billions of dollars are lost to fraud, waste and abuse (FWA). At Codoxo, we see a better way, and we collaborate with our customers regularly so that we can act today to solve tomorrow’s most pressing issues in healthcare.
Codoxo’s inaugural Customer Conference, held October 11-13, brought together clients virtually to network, learn, and share best practices around how to make healthcare more effective, efficient and affordable. During our Product Roadmap Update session, we conducted a series of surveys to inquire with healthcare payer and agency Special Investigation Unit (SIU) leaders about some of their top challenges, key industry trends, and measures of success.
One major theme became repeatedly clear: Our clients are interested in detecting new and emerging fraud schemes—earlier. Let’s unpack these informative survey results, identify today’s most pressing challenges around healthcare cost containment, and discover how Codoxo’s cutting-edge, patented artificial intelligence (AI) technology and its Unified Cost Containment Platform play a critical role in advancing cost containment outcomes.
Tackling the healthcare fraud claims crisis
When we asked our session attendees what their top challenges were, 44% indicated that staying ahead of fraud, waste, and abuse risk was top of mind. This falls directly in line with recent estimates that 3-10% of all U.S. healthcare spending is attributed to FWA. Healthcare has the highest payout of any line of insurance, and fraud expenditures are understandably a major issue. In fact, FWA costs these organizations up to 10% of their annual revenue.
There has long been a need for reform in how SIUs address the issue of FWA and a shift away from traditional detection methods. One of the biggest underlying challenges with FWA detection is that many healthcare plans and agencies operate with siloed systems that prevent a single, unified view of all claims data (professional, facility, pharmacy and dental).
At Codoxo, our mission is to impact unsustainable healthcare costs through our forensic AI platform that empowers SIUs to analyze their data, detect issues, and build connections in ways that other competitors simply cannot replicate. Our technology suite of tools enables SIUs to see anomalies from complex medical claims and codes that traditional methods have no way of detecting.
Download our summary infographic with the session’s polling results.
Shifting towards frictionless cost containment
It is one thing to detect FWA risk but quite another to do so in a way that doesn’t disrupt client relations. Our SIUs pointed out that the second biggest challenge (40%) they face is “managing FWA risk without contributing to provider abrasion.” While a shift-left approach closer to payment or pre-payment models is important, collaboration with providers is the real key to making this process as seamless as possible. This is still easier said than done.
Rajesh Razdan, Codoxo’s VP of Products, points to the need for a more unified approach to healthcare cost containment. More specifically, it’s about “addressing the challenge of cost containment holistically: designing our products to remove the silos that exist today and enable all departments to orchestrate their workflows on a single platform and really benefit from sharing insights and intelligence across reclaim prepayment and post payment workflows.”
But what does this approach look like in practice? An example use case might be where the SIU team is working on a case related to a particular provider, as is the payment integrity (PI) team. By leveraging the power of Codoxo’s Unified Cost Containment Platform, SIU and PI teams can now work from the same claims data, see a holistic view of all cost containment activities and work together to mitigate risk more quickly and seamlessly instead of using disparate systems and siloed data. This not only saves the SIU and PI teams considerable manual effort and cost savings but enables them to coordinate on items such as provider outreach and engagement. Additionally, offering providers peer-to-peer comparisons of their coding and billing patterns and proactively engaging with them to improve claim integrity and bring down pre-claim costs through tools such as self-monitoring and communication portals, helps improve provider education and reduce abrasion.
Another 30% of respondents also shared that increasing collaboration between SIU, PI, and Network relations teams is critical for achieving holistic payment integrity. Codoxo not only creates a high level of transparency across the healthcare claim payment cycle but empowers SIUs and other teams to work together more seamlessly towards fraud prevention and cost savings. Our survey validated these findings as 62% said that identifying and building cases for target dollar recovery was a top measure of success.
Why AI is critical to winning the battle against FWA
When we asked our clients which industry trends, they were most likely to embrace over the next 24 months, artificial intelligence was top of mind. In fact, 44% of survey respondents indicated increasing reliance on AI for identifying FWA leads.
The same study revealed that the second most time-consuming task performed by their SIU is lead identification, where investigation, analysis, and validation of leads was the number one most resource-intensive process. This tells us that the industry is hopeful that AI is their answer, and they need tools to help them capture more accurate leads and fewer false positives.
In a recent internal study performed by Codoxo, we found that Codoxo’s Fraud Scope Solution, which works as a standalone tool, detected nearly all the leads, capturing approximately 97% of exposures. What is more, the Codoxo solution is proven to reduce false positives by 93% and increase productivity by 72%.
Codoxo is leading a movement within healthcare to eliminate the billions of dollars lost annually to fraud, waste, and abuse. By leveraging the power of its proprietary, forensic AI engine, we help healthcare companies and agencies quickly and accurately identify existing and emerging problems and ensure payment integrity across the entire payment spectrum.
Codoxo continues to lead the charge on Fraud Scope success
The global healthcare fraud analytics market is expected to reach $6.33 billion in 2026 at a compound annual growth rate (CAGR) of 27.06%. While healthcare desperately needs quick solutions to stem the rise of FWA, the good news is that advancements in technology and innovation are moving at a rapid pace. Survey results from our Customer Conference session indicate a much greater interest and adoption of AI solutions across the market. We continue to invest significant dollars in research and development and have a large internal team of research scientists who constantly push the boundaries of what is possible with AI.
As Razdan summed up, “We pride ourselves on being customer focused and pushing the limits of innovation.”
Codoxo is committed to leading the charge on transforming healthcare cost containment, and we hope you’ll join us in the fight against FWA by adopting holistic AI-driven solutions.