AI Solutions for Healthcare

Provider-sponsored Health Plans

AI-powered analysis to bring down out-of-network costs and obtain insights into clinical care patterns

Whether you run a provider-sponsored health plan that maintains reserves, or a health system with a staff model, your teams work as a single integrated system to deliver outstanding patient care. And you have lots of data. You know everything about your providers and the care your patients receive within your health system.

But you don’t have this same level of insight and trust with providers outside of your network. And your internal teams can’t easily access the wealth of information you have about your members, providers, care plans and protocols.

That’s why we built the Codoxo Healthcare Integrity Suite. Codoxo gives commercial, state and provider-sponsored health plans an easier way to research issues and accelerate out-of-network authorizations with an AI-assisted clinical cost analysis solution.

Integrated Health Systems

We invest heavily in our people and our technology to help us push the boundaries of what’s possible.
We have helped achieve savings at world-class payers and healthcare agencies including:

Highmark

6+ million members

State Medicaid Agency

1.5+ million recipients

Southeast Health Plan

3.5+ million members

Pacific Health Plan

700k+ members

Mid-State Health Plan

3.5+ million members

Midwest Plan

2.5+ million members

We invest heavily in our people and our technology to help us push the boundaries of what’s possible.

We have helped achieve savings at world-class payers and healthcare agencies including:

Highmark

6+ million members

State Medicaid Agency

1.5+ million recipients

Southeast Health Plan

3.5+ million members

Pacific Health Plan

700k+ members

Mid-State Health Plan

3.5+ million members

Midwest Plan

2.5+ million members

Codoxo helps provider-sponsored health plan leaders control out-of-network costs and get unique insights into clinical patterns. Using our Forensic AI clinical cost analysis solutions provider-sponsored plans can accelerate out-of-network authorizations and give everyone access to behavior-based insights.

Forensic AI Engine analyzes your out-of-network claims data, identifies practices that intentionally or unintentionally waste money, and builds connections across your data to provide actionable insights.

AI analyzes all claim types and Codoxo can easily ingest all professional, facility, pharmaceutical, behavioral, dental, and workers comp claims.

Patented-AI analyzes all codes to identify issues and opportunities that may arise from complex claims and codes in addition to the standard ones which helps discover a wider range of existing and emerging problems.

Automatically and accurately detect existing and emerging fraud schemes with an AI-assisted solution for provider-owned plans.

Easy-to-use reports and queries democratize access to claim, provider, facility and member insights and gives everyone across your teams’ behavior-based context.

Accelerate emergent decisions and out-of-network prior authorizations with AI-assisted reviews and integrity checks.

codoxo product diagram

AI Solutions for Healthcare

codoxo product diagram

The Codoxo Healthcare Integrity Suite gives you a powerful way to identify problems and take action to control costs with a full set of applications that help each team quickly research issues and get behavioral context to inform and accelerate the best next step.

– Kurt Spear, Vice President Financial Investigations and Provider Review
HIGHMARK

Ready for a better solution?

Request a demo to learn what we can do for you.

FORENSIC AI PLATFORM

Our Forensic AI Engine analyzes your data, detects problems, and builds connections across your data to provide actionable insights

Insight Scope

For everyone across the health plan

Clinical Scope

For clinical teams

Network Scope

For network teams

Payment Scope

For payment integrity teams

Provider Scope

For network and payment teams

Fraud Scope

For SIU teams

SERVICES

We provide a full range of professional services, from data migration and ongoing customer success through flexible virtual SIU options.

Fraudscope is now Codoxo. LEARN MORE >