Pacific Blues Health Plan

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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