In healthcare payment integrity, earlier intervention drives better outcomes. For too long, healthcare payers have been forced to chase errors after claims are created—through costly pre-payment reviews or even post-payment recovery. By that point, provider frustration is high, administrative costs are mounting, and valuable reimbursement dollars have already slipped away. These improper payments weaken the healthcare system and create avoidable abrasion.
Codoxo’s Point Zero Payment Integrity model changes that equation. By moving interventions further left in the claim lifecycle—before a claim is even submitted—health plans can proactively educate providers on coding practices, billing accuracy, and reimbursement policies. The result: fewer errors, stronger provider relationships, smoother claims processing workflows, and significant healthcare cost avoidance.
This approach isn’t theory—it’s working in the real world. One health plan is leveraging Point Zero’s provider education programs to eliminate recurring issues at the source, reduce claim denials and appeals, and create millions in sustainable savings year over year.
A Leading Health Plan Takes Action
One leading Blues health plan had already been leveraging Codoxo’s AI-driven solutions to reduce fraud, waste, and abuse. But leadership saw a new opportunity: to tackle rising costs tied to billing practices and coding errors at the source—before claims were ever created.
To make this shift, the plan implemented Provider Scope,Codoxo’s AI-driven provider education platform. The solution identifies anomalies across billing practices, surfaces outliers in real time, and delivers transparent insights to both payers and providers through a secure, HIPAA-compliant, self-service portal.
Because Provider Scope integrates seamlessly into the Availity portal, providers could check claim status, manage submissions, validate reimbursement policies, and access outreach and education resources right within their existing workflow—streamlining participation without disruption.
What Makes Point Zero Different
Traditional payment integrity programs, even those considered “pre-payment,” still operate after a claim is created. That means denials, resubmissions, audits, and case management remain unavoidable. While these methods do protect against overpayments and ensure some claim integrity, they also increase administrative burden and strain provider networks.
Point Zero Payment Integrity moves further left than ever before—into the pre-claim space. By identifying risks and educating providers ahead of submission, payers prevent errors from entering the healthcare payment process at all. Instead of reacting after adjudication, payers and providers work together in partnership to ensure claim accuracy from the start.
This approach represents a paradigm shift: from enforcement to enablement. It transforms payment integrity from a cost center into a value driver—cutting waste, minimizing abrasion, and fostering trust at scale.
$20 Million Saved in Year One, with Quarterly Recurring Savings
The results were immediate—and exceeded expectations:
- $20M+ in savings, 25% above forecast in the first year
- High provider engagement, with physicians actively correcting billing accuracy once they saw the AI-driven insights
- Fewer coding errors, leading to improved cost containment and smoother adjudication
- Stronger payer–provider relationships, thanks to an educational, non-punitive approach
Provider Scope has continued to deliver recurring quarterly savings, keeping results on pace with year-one performance. That kind of consistency proves the long-term ROI of pre-claim provider education—turning initial success into a reliable, repeatable outcome for healthcare payers.
A Simple Fix, a Big Impact
One provider story includes a rendering physician who discovered her billing entity had been automatically applying Modifier 59 to all claims, leading to unnecessary payments. After receiving an educational letter generated through Provider Scope, she quickly contacted her billing service and corrected the issue—grateful for the supportive, non-punitive approach instead of facing penalties or claim denials.
It’s a powerful example of how provider education and outreach change behavior in ways enforcement never could.
A Blueprint for the Future of Payment Integrity
The regional health plan’s success is a compelling example of what’s possible when payers embrace Point Zero Payment Integrity. By moving intervention earlier than ever before—into the pre-claim space—payers can drive measurable reimbursement improvements, streamline workflows, and minimize abrasion.
As healthcare costs continue to rise, medical records grow more complex, and policy changes evolve, payers can’t afford to rely solely on catch-and-correct methods. The future of healthcare payment integrity starts at Point Zero—where providers are partners in prevention, claim validation happens in real time, and payment accuracy is built in before adjudication.
To learn more about Codoxo’s Point Zero solutions, visit https://pointzeropaymentintegrity.codoxo.com/