CASE STUDY
National Health Plan
Codoxo Validates Fraud Scope Catches 97% of Post-Payment Exposure
“Rules-based systems are good for things that don’t change often. Codoxo’s AI catches new problems that are evolving and may otherwise slip through the cracks of a rules-based system.”
Background
A large national health plan uses Fraud Scope, an AI-based fraud, waste, and abuse (FWA) detection platform, to monitor existing and emerging FWA schemes on an ongoing basis. When the client team began noticing large dollar amounts for paid exposure and a significant number of high-risk scores on the Fraud Scope dashboard, they reached out to Codoxo for further insight.
Solution
The team wanted to compare these new FWA findings against cases they had initiated based on leads identified from multiple other sources, such as hotlines, law enforcement, and other payment integrity vendors, along with internal manual efforts. Two questions needed to be answered: how many of these leads would have been identified if Fraud Scope was the only tool used? Did Fraud Scope identify other tangible leads? The Codoxo team conducted an internal comparison study to determine how Fraud Scope would have performed had it been the only platform providing this critical information.
The results were impressive:
• Codoxo’s Fraud Scope Solution, as a standalone tool, detected nearly all of the leads, capturing approximately 97% of exposures. Notably, Fraud Scope only identified 8% of the providers
• Fraud Scope identified several other high potential leads amounting to thousands of additional exposures.
• Fraud Scope assigned a high-risk score of 40+ to every provider with $1 million or more in potential exposure,
This comparative study clearly demonstrated that Fraud Scope was not only able to detect nearly all the leads that were identified by a multitude of tools, but it also helped prioritize leads based on exposure. Furthermore, Fraud Scope identified additional high-potential leads that were missed by other tools. Some innovation-minded healthcare payers have started to deploy such highly accurate detection and prioritization solutions upstream in the claims payment process, as early as post-adjudication pre-pay stages, where savings opportunities are the greatest and provider abrasion is at its minimum.
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“Codoxo’s Forensic AI Platform is a game-changer. AI is helping us identify, prevent, and stop potentially fraudulent activities earlier than ever.”