As digitization trends continue to skyrocket and consumers expect faster and more seamless user experiences across services, products, and platforms, the same expectations have also arisen in healthcare. Why, after all, shouldn’t a consumer who uses their Apple Watch to monitor health metrics, be able to expect retail-like customer experiences when scheduling an office visit or paying a bill? Indeed, healthcare consumerization has become a significant movement in recent years as patients have asserted more control over their own healthcare decisions and pushed for more transparency and affordability across the system.
One of the most promising trends in healthcare consumerization has been in cost containment – in particular, using artificial intelligence (AI) and machine learning (ML) to identify fraud, waste, or abuse (FWA) schemes across the healthcare system faster and earlier to minimize financial exposure. With FWA accounting for 3-10% of skyrocketing healthcare costs, Codoxo was born in 2017 to transform the healthcare cost containment landscape through forensic AI-powered solutions. This vision has come to life, with Codoxo empowering healthcare payers, agencies, and pharmacy benefits managers since inception.
Let’s take a closer look at the rising trend of consumerization in healthcare cost containment and how Codoxo is playing a leading role.
Trends in healthcare consumerization & AI cost containment
By now, most consumers have experienced some form of “consumerized” healthcare innovation in their own lives: virtual medical consultations, easier scheduling tools, payment record portals, and a growing range of remote health monitoring apps. But behind the scenes of what everyday patients and health plan members see when visiting doctors or paying bills are health tech innovators – companies that are deeply focused on making payment processes easier, more secure and less vulnerable to fraud by applying AI/ML to detect anomalous, erroneous and suspicious claims that burden the healthcare system unnecessarily.
AI in healthcare is a hot topic, even going viral in recent months due to the prominence of conversational apps like ChatGPT. But AI as an underlying technology has been around for many years and its adoption into healthcare fraud detection is not new.
But here’s what is new: AI built from the ground up specifically for healthcare; AI not yet seen before within cost containment; AI that melds self-learning technology with rules-based models to deliver more accurate, faster and effective detection and insights. Then building this AI into a single platform that works across the healthcare cost containment spectrum, spanning payment integrity, FWA, provider coding and billing education, network management, prior authorization acceleration, and more.
What’s new is that cost containment teams finally have access to real-time insight that empowers lasting change. Codoxo’s AI-driven platform delivers information to frontline leaders of today’s cost containment revolution, helping to stop the bleeding and its negative bottom line impact to our nation’s healthcare system.
This is Codoxo’s unique domain: bringing together healthcare payers, providers, pharmacy benefits managers and their teams (SIUs, payment integrity and the like) on a groundbreaking AI-based cost containment platform that generates savings and recoveries more efficiently than ever before.
Real world examples of “consumerized” healthcare AI in action
The public often hears about healthcare’s spiraling costs, and the billions of dollars lost each year to FWA. In response to these growing challenges, Codoxo has sparked a movement aimed at helping healthcare organizations achieve payment transparency and accuracy with as little abrasion as possible.
Consider the speed, transparency, and outcomes generated by leading-edge FWA solutions like Codoxo’s Fraud Scope and Audit Scope. From superior detection to highly-visual integrated audit workflows, these solutions empower SIU and Payment Integrity teams to work together to identify and mitigate FWA issues quickly, saving costs and providing a more efficient approach to healthcare payment accuracy.
Another example of cost containment innovation is in the realm of provider education. Codoxo’s Provider Scope uses AI to accurately detect outlier provider billing and coding behavior and encourage providers to improve claim integrity earlier in the payment cycle – thus “shifting left” by engaging with providers sooner to change behavior in a non-threatening manner.
How are healthcare payers using these innovations in their day-to-day FWA and payment integrity operations? Here are three BCBS customer examples from Codoxo:
- An eastern U.S. BlueCross BlueShield health plan began using Fraud Scope to discover erroneous billing trends for higher level psychotherapy codes and combinations of high-level psychotherapy and E&M services. With nearly immediate success in the recovery of healthcare dollars, process improvements, and projected savings, this payer expanded its program with Codoxo for further identification of fraud leads and to uncover billing and payment errors.
- A midwestern U.S. BlueCross BlueShield health plan aimed to curtail major losses by improving its ability to detect and protect against outlier billing behavior, such as claims billed under medical insurance for non-traumatic dental services. After just a few weeks, the payer was able to leverage Codoxo’s AI platform, holistic data insights, and expertise to discover erroneous dental billings, analyze medical and dental claims to identify instances of unbundling of codes at the service and provider levels, and implement best practices to avoid erroneous billings in the future.
- A pacific U.S. BlueCross BlueShield health plan wanted to trial a more reliable FWA platform to help detect what they couldn’t see to avoid further loss and maximize recoveries. Fraud Scope did just that, by identifying a male testosterone injections/lifestyle enhancements scheme that exposed the insurance provider to $2.2M in overpayments, and detecting a potential outlier upcoding for over $800K for testosterone and intramuscular injections billed as a medical benefit.
Takeaways
As consumerization of technology continues its quest for faster, more efficient and cheaper goods and services, the healthcare industry also continues to experiment with making patient interactions as seamless as possible. Thanks to innovative AI platforms like Codoxo, healthcare cost containment has now emerged as an industry-wide movement.
Here’s the hard truth coupled with a promising premise: as healthcare innovators continue to experiment with new delivery models, including telehealth and the possibility of home doctor visits, opportunistic bad actors will continue to exploit the system.
Codoxo’s Unified Cost Containment Platform offers the tools and resources to identify outlier behavior early, gain an accurate, holistic and actionable view of data, claims, providers and members, and stop financial loss to maximize savings and recoveries.
Join our movement in the next big step towards healthcare payment transparency and integrity. To learn how Codoxo can help your healthcare organization innovate with AI, please contact us at info@codoxo.com or visit our website at www.codoxo.com.