State Medicaid Agency

AI-based Fraud Detection Solution Helped Program Integrity Unit at State Medicaid Agency Realize a 1,500% ROI in 12 Short Weeks

Background

The Program Integrity unit within this fee-for-service state Medicaid agency was hindered by a lack of cohesive analytic capabilities and technologies and highly manual processes, creating limited reporting. The team, comprised of analysts and investigators, needed a single platform view of claims and cases. Yet, their current tools were unable to help them quickly identify current, new, or emerging fraud trends. The program integrity team was highly reliant on their IT department to run trend reports for visibility into outlier and suspicious behavior and lacked a single solution for both the analysts and investigators to use, creating silos within the department for cases needing further investigation. 

Solution

Within a few short weeks of using Codoxo’s Fraud Scope AI platform, the agency knew there was significant potential for return and expanded the scope from a limited number of professional specialties to all specialties at the state Medicaid agency. Fraud Scope quickly surfaced existing and emerging trends and schemes to the analysts who could easily see why the providers were flagged and determine if further action was needed. Within the same Fraud Scope solution, the analysts created cases to then turn over to an investigator for further examination. The investigators used Fraud Scope as a single source of truth to dig deeper and view all data and intelligence needed to take action. 

Outcome

• Within the initial three month limited-scope program, the agency realized: 

• Over 1,500% ROI
• Over $4M in back billing opportunity
• Nearly $7M in total risk exposure
• Overall estimated hard recovery of over $1.7M 

• Projected 5,500+% ROI for professional claims 

• One case alone identified an outlier provider for audit, including nearly $2M of potential recoupment for the agency. Fraud Scope surfaced alarming levels of billed hours, number of patients, out of specialty billing, and many more behaviors indicating potential fraud, waste, and abuse 

• A decision by the agency to expand Fraud Scope to not only include facility and dental claims, but increase scope to include over 2.5 million members, which encompassed their Fee-for-Service (FFS), Care Management Organization (CMO), and State Employee Lines of Business 

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 “Codoxo’s speed of delivery and rapid insights is unmatched in the industry today and allows our clients to quickly identify new or emerging fraud trends, patterns, and leads/cases. Our ability to deliver fast ROI helps our clients contain costs and ultimately protects their bottom lines.”

– Rena Bielinski, PharmD, AHFI, VP of Customer Success, Codoxo