Codoxo Introduces Audit Scope, an AI-Enabled Audit Case Management and Workflow Solution for Health Plans and Pharmacy Benefits Management Organizations

Codoxo, a trusted provider of healthcare artificial intelligence solutions for healthcare payers and agencies, unveiled Audit Scope, the latest addition to its Healthcare Integrity Suite of AI-enabled solutions that battle healthcare fraud, waste, and abuse and ensure payment integrity. Audit Scope supports all functions of a Pharmacy Benefits Management (PBM) or health plan’s audit and workflow process, including seamless integration of detection, selection, audit creation, tracking and reporting of audits across all pre-pay and post-pay functions.

Audit Scope creates a single view across all claims, audits and departments and helps healthcare organizations ensure compliance and efficiencies, including:

• Client/internal contract and government compliance across state, federal, and client-defined requirements.
• Rapid and accurate detection of potential claims and/or providers for audits when paired with fraud detection and rules-based algorithms.
• Deep insights into reasons for detection, including peer-to-peer comparisons, provider performance, and claim level details.
• Easy and intuitive review and selection workflow, allowing auditors to drill into each provider or claim and quickly identify and collect supporting claims to add to audit queues or cases.
• Flexibility for audit teams to create manual, rules-based, or AI-detected audits.
• Seamless transition from pre-pay to post-pay.
• End-to-end case management module for managing all aspects of an audit case, including notes, supporting documentation, provider communications, financials, recoveries and reporting.
• Integrated communication capabilities, including HIPAA compliant email, fax, and postal mail.

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“Given the high level of scrutiny of the industry and drug claims in general, auditing pharmacy claims is an extremely important and necessary function to weed out bad actors and identify fraud. Pharmacy claims audits can benefit greatly from innovations in artificial intelligence (AI) to create an automated and more accurate audit result, and which finds trends or patterns that might be indicative of schemes, waste and errors.” Thomas Faloon, Chief Operating Officer, Pharmacy Data Management, Inc. (PDMI)

PDMI partnered with Codoxo in 2021 to help fight fraud, waste and errors and create more accurate and automated audits through Codoxo’s innovative solutions based on the company’s Forensic AI Platform. Codoxo’s Forensic AI Platform is a patented AI engine that analyzes healthcare claims data, detects practices that intentionally or unintentionally waste money, and builds connections across data to provide actionable insights. For health plans across the country, Codoxo’s Forensic AI Platform has identified over $500 million in savings in just a few years, and reduced false positives in fraud detection by 93 percent.

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“AI works best when it benefits all parties involved in healthcare claims processes, and Audit Scope is no exception,” stated Musheer Ahmed, Codoxo’s Chief Executive Officer. “Auditing for fraud, waste, and abuse in pharmaceuticals isn’t just about cost avoidance or reduction for health payers or PBMs. There can be serious patient safety and business risks revealed that save lives, not just dollars.”

Audit Scope is the latest addition to Codoxo’s Healthcare Integrity Suite, which comprises Fraud Scope, Payment Scope, Provider Scope, Insight Scope, Network Scope, and Clinical Scope. These solutions work together and individually to ferret out fraudulent, erroneous or suspicious claims for healthcare organizations.

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