Every year, billions of dollars are lost to fraud, waste, and abuse (FWA) within the healthcare industry. At Codoxo, we see a better way to tackle these issues by leveraging innovative AI technologies and collaborating closely with our customers. This year’s Codoxo Xcelerate Conference, held October 22-24, shed light on how our AI-driven solutions are helping healthcare payers enhance their fraud detection capabilities for the greatest recovery potential.
AI-Driven Fraud Detection Success Stories Shared by Fraud Scope Customers
The Codoxo Xcelerate Conference brought together the Codoxo community of users to share and learn about the effectiveness of our AI-powered Fraud Scope tool in detecting providers warranting further review. SIU Directors, Managers and Investigators illustrated how their teams have successfully used Codoxo’s solutions to identify potential fraud, reduce false positives, and/or focus on genuine threats during the session, “Interactive Round Table: Utilizing AI for Fraud Detection with Fraud Scope Customers”. Below is a high-level recap of the stories shared by our customers.
A Western Plan’s Autonomic Nervous System Testing Investigation:
A Western plan shared an impactful case where Fraud Scope was instrumental in identifying improper billing for autonomic nervous system testing. The investigation revealed that multiple family physicians were billing for tests typically performed by neurologists, leading to significant financial recovery and preventive measures. “We identified overpayments of about $120k and recovered most of that,” noted a team member. This case underscores Fraud Scope’s ability to pinpoint improper billing patterns and facilitate efficient recovery efforts.
A South-Central Plan’s Genetic Testing Anomalies:
A team member from a South-Central region plan discussed the detection of pattern-based genetic testing claims. By leveraging Fraud Scope, her team identified over-utilization of certain testing codes, resulting in the recovery of funds and removal of non-compliant labs from their network. “The way that we really found benefit with Codoxo is being able to find those outlier providers that we wouldn’t have normally looked at, but we’re able to look at because it’s flagged.” she revealed, emphasizing the tool’s ability to uncover unexpected outliers and address systemic fraud.
A Northeast Plan’s Midwife Billing Irregularities:
An employee from a Northeast plan highlighted a significant case where midwives were billing critical care codes in conjunction with home births. Fraud Scope’s analytical capabilities enabled the team to place the provider on prepayment review, saving the organization a substantial amount. “This resulted in a total savings of $1 million,” the team member reported, demonstrating the platform’s effectiveness in preventing unnecessary payouts.
A South-Central Plan’s COVID-19 Test Distribution Fraud:
The team member from a South-Central region plan returned to share another remarkable case involving unauthorized distribution of at-home COVID tests by pharmacies. “We reviewed 442 pharmacies altogether… About 80% of the tests were being supplied to the members when they were not requested…paid out over $21 million for all the tests.” Fraud Scope aided in identifying the fraudulent billing patterns and limiting further financial losses.
An Eastern Health Plan’s Improbable Days Billing:
An employee from an Eastern U.S. health plan discussed the detection of improbable billing days, where providers billed for a suspiciously high number of service hours. Fraud Scope’s detection capabilities helped corroborate findings from other data sources, leading to ongoing investigations and significant exposure savings. “The exposure between the two of them combined was over half a million dollars,” he noted, highlighting the platform’s robust detection features.
A Northeast Plan’s Behavioral Health Billing Examination:
A Northeast plan recounted a case involving improper billing practices for behavioral health services and the use of Spravato treatments. Fraud Scope played a crucial role in identifying billing inconsistencies and facilitating substantial financial recoveries. “The recovery amount was around $66,000,” a team member stated, emphasizing the tool’s impact on ensuring billing accuracy and compliance.
Benefits and Outcomes
Throughout the conference, speakers highlighted the advantages of using Fraud Scope, including enhanced detection capabilities, significant cost savings, and improved investigative processes. The tool’s ability to quickly identify and address fraudulent activities has not only led to financial recoveries but also strengthened the integrity of billing practices across various health plans.
Codoxo Continues to Lead the Charge on FWA Success
As the healthcare fraud analytics market grows, Codoxo remains committed to leading in innovation and research and development to combat FWA. We encourage healthcare leaders to explore how our AI-driven solutions can transform cost containment.
For a detailed conversation about our offerings, please contact us at info@codoxo.com.
Let’s work together to curtail the healthcare fraud crisis and optimize cost-containment strategies for a more secure and efficient system.