National Health Plan Payment Integrity Case Study

This case study outlines the engagement of a leading national health plan with Codoxo’s AI-Powered Data Mining Services to uncover previously undetected payment integrity opportunities. The health plan, which had a mature payment integrity program, sought an independent assessment of its historical claims data to identify any additional savings opportunities that may have been overlooked. Codoxo analyzed multiple years of datasets, encompassing 37 million claims and over $20 billion in paid claims, using advanced AI models. The assessment revealed foundational payment integrity issues, reimbursement policy enhancement opportunities, and additional concepts for future evaluation. The collaborative approach between Codoxo and the health plan led to the identification of over $60 million in payment integrity exposure and $30 million in validated opportunities for recovery. The findings provided actionable recommendations to strengthen eligibility and reimbursement policies, as well as a repeatable framework for continuous improvement in payment integrity controls.