AI Solutions for Healthcare

CASE STUDY

Pacific Blues Health Plan

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Pacific Blues Health Plan Uses Fraud Scope to Identify Millions in Overpayments From a Single Scheme

A leading Blues healthcare payer in the Pacific U.S. needed a more robust AI solution for mitigating fraud, waste, and abuse (FWA) within their insurance network. They sought a partner and platform that would improve SIU operations and outcomes, including:

• Meeting compliance mandates
• Detection of outlier claims and behavior
• Codoxo’s AI identifies provider behavior that is outside the norm
• Better usability, efficiency and FWA recoveries

Of particular interest to the health plan was being able to use AI to maximize FWA recoveries and identify previously unknown FWA schemes. Not only was their original platform not user friendly, but the analyst team needed a faster and more reliable solution to drive better outcomes.

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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

Audit Scope

For everyone across the health plan and PBM

Network Scope

For network teams

Payment Scope

For payment integrity teams

Provider Scope

For network and payment teams

Fraud Scope

For SIU teams

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