Bring down costs pre-claim with unique provider and facility insights
Provider Scope compares each providers’ claims and coding practices to their peers, identifies outlier behavior, and proactively engages providers to improve claim integrity and bring down pre-claim costs with a provider self-monitoring and communication portal.
Provider Scope allows payers and healthcare companies to efficiently reduce coding errors and influence healthcare costs prior to submission of claims while decreasing provider abrasion.
Our healthcare provider cost management AI software is popular with Chief Medical Officers, Provider Education and Network teams at healthcare companies and agencies and includes:
Patent-pending AI creates dynamic peer groups
defined by specialty based on credentialing information or NPPES registry with verification.
identifies providers whose billing behavior is far above their peer group and flags the specific outlier coding practices.
Complement existing staff
with expanded claims monitoring to achieve significantly larger ROIs.
make it easy to see the problematic providers and specific coding behaviors driving up costs compared to their peers and helps payers compare and monitor claim patterns that are a concern.
Automated provider outreach via email or letter
informs providers about their billing patterns, explains why the provider was identified as an outlier, and gives them personal link to your portal with a one-time access code for security. Single sign-on (SSO) available.
Provider Self-Monitoring & Communication Portal
can be co-branded and shows each provider or facility how their coding practices compare to their peers. Self-monitoring brings transparency and improves provider education engagement.
Visually rich charts
help providers compare and monitor certain code patterns that are of concern to your health plan and understand why their billing pattern were identified as an outlier.
Certified coder staff available
to provide coding best practices and discuss why the provider has billed the way they have to understand the valid reasons for their billing patterns.
Re-evaluates provider outlier status every quarter
and shows coding behavior changes over time.
Ongoing monitoring, alerts and follow ups:
If a provider’s billing practice remains a concern for a quarter after the initial contact, a second communication will be sent along with updated trend information within the platform. Health plan teams are notified of providers whose billing practices remain a concern for two consecutive quarters if they don’t have a justifiable reason for their outlier billing pattern.
Reporting and collaboration
plans will have ability to track provider engagement with the online portal and share information about specific providers with other teams.
all claim types
Codoxo can ingest and analyze all professional, facility, pharmaceutical, behavioral, dental, and workers comp claims.
Our patented AI technology has the ability 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.
Provider Scope is built on our Forensic AI Platform and a part of the Codoxo Healthcare Integrity Suite
Our AI engine analyzes your claims data, detects practices that intentionally or unintentionally waste money, and builds connections across your data to provide actionable insights.
Saving millions at world-class insurance companies and healthcare agencies including:
State Medicaid Agency
2+ million recipients
Southeast Blue Plan
3+ million members
Midwest Blue Plan
2.9 million members
Pacific Health Plan
"Codoxo's Forensic AI Platform is a game changer.
– Kurt Spear, Vice President Financial Investigations and Provider Review
Ready to get started?
Talk with a sales rep to get a demo of Codoxo and learn more.