AI Solutions for Healthcare

Provider Scope

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.

Post-pay analysis

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.

Side-by-side charts

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.

AI analyzes
all claim types

Codoxo can ingest and analyze all professional, facility, pharmaceutical, behavioral, dental, and workers comp claims.

AI analyzes
all CODES

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

Codoxo_ProductStackDiagram_ProviderScope

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.

Codoxo_ProductStackDiagram_ProviderScope

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

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 >