Fraud Scope
Automatically and accurately detect existing and emerging fraud schemes with an AI-assisted solution
Fraud Scope automatically detects new and emerging fraud schemes, streamlines the collection of evidence chains, and gives SIU teams integrated case workflow for the FWA investigations you choose to pursue.
Our AI-assisted fraud, waste and abuse detection solution is popular with SIU teams and those individuals focused on reducing FWA costs at major healthcare companies and agencies across North America. It includes:
Forensic AI Platform detects problems earlier
and can quickly identify new, emerging, and existing fraud schemes with very low false positives
Clear scheme explanations
make it easy for everyone using the Fraud Scope application to quickly get up to speed on the newly identified problem, or see the full history of a well-known scheme
Prioritization of suspicious claims
based on the Codoxo Claims Risk Score and dollar amounts to maximize savings
Evidence chains
are automatically gathered by the Forensic AI Platform, clearly presented to SIU teams, and users have the ability to deep dive and validate the AI findings if they choose to do so
All-in-one case management
brings together all the information related to a suspected FWA issue, including full notes and event history, related claims tracking, document repository, financial impact, user assignments and case logs. Each client may customize the Fraud Scope case template for your specific fields and process
Integrated workflow
supports collaboration and information sharing across the organization
Smarter ad-hoc investigations
with easy-to-use queries and self-service reports that are easy to customize – without any help from IT
Complements existing analysis techniques
and can integrate data from your existing intelligence feeds
Patent-pending AI analyzes claims
and gives you unique behavioral insights into every provider, facility, pharmacy and member involved
New risk alerts and active watchlists
flag claims from providers, facilities, pharmacies or dental practices suspected of FWA activities
Provider Integrity Score
indicates whether or not providers are associated with any new or existing fraud schemes, or have recent coding practices that fall outside the norm of their peers. Fraud Scope gives SIU teams detailed explanations for each provider integrity score
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.
Fraud Scope is built on our Forensic AI Platform and a part of the Codoxo Unified Cost Containment Platform
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.
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.