Provides an AI-powered platform for healthcare payers and agencies to detect and prevent fraud, waste, and abuse in claims processing. By analyzing healthcare data with a patented forensic AI engine, it identifies payment integrity issues and reduces false positives, saving clients hundreds of millions annually while improving operational efficiency.
Funding
$32.1M raised to dateRaised to date based on public sources. This may differ from the amount the company actually raised and is based only on what is publicly available on the internet.
Founders
Product
Problem
Healthcare payers and agencies face significant financial losses due to fraud, waste, and abuse (FWA) in claims processing, which existing detection methods often fail to identify accurately, leading to substantial overpayments and administrative inefficiencies. Traditional methods struggle to keep pace with evolving fraud schemes and often generate high false-positive rates, burdening payment integrity teams and straining provider relationships.
Solution
Codoxo offers a Unified Cost Containment Platform that leverages generative AI and self-learning AI to address payment integrity challenges. The platform analyzes healthcare claims data to detect anomalies, identify potential FWA, and provide actionable insights for cost containment. By intervening earlier in the payment cycle, Codoxo enables proactive provider education, reduces abrasive payment integrity activities, and strengthens payer-provider relationships. The platform's comprehensive suite of AI-powered solutions covers provider education, network services, payment integrity, and Special Investigation Units (SIU), integrating prepayment and postpayment processes for efficient and effective cost management.
Target Audience
The primary customers are managed care plans, Medicaid agencies, employer-sponsored plans, union-sponsored healthcare plans, provider-sponsored health plans, pharmacy benefit managers (PBMs), and federal agencies.
Features
- Forensic AI Engine: Patented AI technology analyzes data to detect payment integrity issues and build connections across data for actionable insights.
- ClaimPilot: Generative AI automates medical record reviews, validates provider contracts and medical policies, and accelerates concept development of new claim payment methods.
- Provider Scope: Proactive and automated provider education to bring down costs pre-claim.
- Audit Scope: Automates and streamlines end-to-end audit detection and workflow while ensuring compliance.
- Fraud Scope: Automatically and accurately detects new and emerging fraud schemes and streamlines evidence chain collections for FWA investigations.
- Payment Scope: Identifies claim accuracy issues before claims are paid with unique claim insights, easy-to-use claim workflow, and automated provider outreach.
- Virtual SIU Services: Offloads SIU compliance and scale operations through end-to-end virtual resources and services.