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Dr. Musheer Ahmed, Codoxo: “rising costs of the healthcare system remains a major concern”

Fraud incidents are always bad news. Sadly, fraudsters are not backing out, especially when speaking about healthcare.

Even though scams in the healthcare industry pre-date COVID-19, the pandemic has highlighted the importance and fragility of this sector. The consequences of healthcare fraud can lead to a lack of funds to buy necessary medical equipment or crucial procedures being left unperformed.

While there are many ways criminals take advantage of the healthcare system, our guest points out four, probably the most damaging tactics, costing institutions millions of dollars every year, and even placing patients at risk.

In order to discuss this topic and analyze healthcare-related fraud, the Cybernews team contacted Dr. Musheer Ahmed, CEO of Codoxo – a company, which builds AI solutions that help healthcare companies to identify problems.

Tell us a little bit about your story. How did Codoxo originate?

Codoxo’s core technology was developed and patented as a part of my Ph.D. dissertation at the Georgia Institute of Technology. A report by the JASON advisory group, the prestigious scientific advisory panel to the US government, reinforced that my doctoral research tackled some of the biggest challenges within the emerging healthcare data infrastructure in the United States.

From there Codoxo was formed and I, along with my team, began to leverage our proprietary AI to tackle one of the biggest challenges facing skyrocketing costs within the U.S. healthcare system - fraud, waste, and abuse which costs the US hundreds of billions of dollars each year. Our mission is to make the U.S. healthcare system more affordable and effective for everyone.

Can you introduce us to your platform? What technology do you use to analyze large amounts of data?

Each year hundreds of billions of dollars are lost to fraud, waste, and abuse in healthcare. With millions of claims coming into healthcare organizations, payers, and government agencies, it’s hard to distinguish between appropriate care, a simple coding mistake, and intentional fraud.

Codoxo’s AI platform gives these entities a powerful way to detect new problems and take action to control costs – before they add up to a big hit on the bottom line and billions of dollars lost to fraud, and waste. This is where Codoxo and its Forensic AI Platform step in.

Codoxo’s Forensic AI Platform analyzes claims data, detects practices that intentionally or unintentionally waste money, and builds connections across data to provide actionable insights. Its AI engine analyzes all types of claims through its:

  • Behavior-based Analysis: Analyzes professional, facility, pharmacy, behavioral, dental, and workers comp claims and identifies behavior patterns at every level – from individual claims and providers up through groups, networks, and plans.
  • Detection Engine: The Forensic AI Platform’s patented algorithm uses a combination of rules and artificial intelligence to identify new problems and outlier behavior earlier and more accurately than traditional techniques.
  • Prescriptive Insights: AI measures and gathers data to generate actionable insights that help teams prioritize, influence behavior, and act quickly when there is a problem.

What are some of the most common fraud schemes in the healthcare industry today?

There are several healthcare fraud schemes, costing companies millions of dollars every year, and even placing patients at risk. One of the most common is suspect billing of medical services. Some more recent include:

  • Telehealth schemes: Relaxed regulations and requirements opened the door for new schemes in telehealth. And while there are a lot of things a doctor can do virtually with a patient there are certain things that simply cannot be done unless the doctor is physically present with the patient. The unique advantage of working with AI is that even if we’ve never seen or imagined a particular scheme before, AI, like Codoxo’s, will find it and bubble it to the top, alerting you of suspicious behavior.
  • Physical therapy schemes: This winter, Codoxo’s AI uncovered alarming emerging trends in physical therapy treatment that health plans and agencies were alerted to. Some of these were related to specific laser therapy and cold or warm superficial or deep tissue therapy, with codes for services that were outside the scope of what physical therapists are permitted to perform and/or were identified by Codoxo as “unlikely services.”
  • Provider schemes, oncology: While most healthcare providers are amazing people who’ve answered a calling, as in all professions, there are a few bad apples. One particularly heartbreaking example of fraud that the Codoxo AI detected was an oncologist who began reporting that every patient who came to him had cancer and required a full battery of chemotherapy treatment. Unfortunately, this wasn’t the case. He was forcing patients through unnecessary appointments and chemo as a money-making scheme.
  • Provider cardiology schemes: Another recent example of a provider turned bad, but caught by AI is a cardiologist that was pushing a large number of patients to go through stent surgeries by telling them the surgery was critical within the next day or two or they might suffer a massive (and probably deadly) heart attack. Codoxo’s AI was able to identify these outliers and alert payers that there may be a suspicious activity that might not just save them money, but potentially save patients pain and suffering that isn’t necessary.

How did the recent global events affect your field of work? Were there any new challenges you had to adapt to?

Obviously, COVID-19 created an opportunity for people with bad intentions to take advantage of that situation. A surge of COVID-19-related schemes emerged since the pandemic, including a heightened focus on lab testing. One example would be that several bad actors began creating something called a “COVID Panel” where they would run a group of tests and charge insurance companies. There is no such thing as a COVID Panel and this was something that AI was able to identify very, very quickly, saving tens of millions of dollars.

Another big change in healthcare due to the pandemic has been the rise in telemedicine. While virtual care has its benefits and can be delivered at a lower cost, the relaxed regulations and our own study found between 10% to 15% of non-compliance with CMS-recommended telehealth codes, underscoring the importance of detecting potential fraud, waste, and abuse, plus the need for provider education.

Since the use of telemedicine increased, providers have had to keep an eye on evaluation and management (E&M) upcoding, where providers claim to provide a higher level of service than actually delivered or claim services that are physically impossible to deliver via a telemedicine consult.

In your opinion, what types of organizations should be especially concerned about adopting AI solutions?

Any company that handles digital data has an opportunity to embrace AI solutions and reap the benefits, but that will look different for different industries and companies. But if we look at AI in healthcare, there is tremendous upside for digital transformation through AI. Here, many internal processes are still being done manually and have repetitive tasks.

On top of that, healthcare data is incredibly complex and has infinitely more characteristics and variables than in most other industries. Adopting sophisticated AI capabilities that are proactive can identify anomalies in near real-time and with incredible accuracy can help to control costs before they hit the bottom line.

Why do you think companies often hesitate to try out new and innovative solutions that would enhance their operations?

Hesitancy to adopt AI in healthcare is not surprising when considering some of the challenges this industry faces. Legacy technology systems that operate inefficiently are common. And with a large amount of M&A activity in the space, many organizations are then faced with isolated legacy systems that don’t have one single location or process for managing claims.

Also, healthcare organizations manage various types of claims, including professional, medical, facility, pharmacy, vision, and dental claims without a unified view across all claims and the patient. The challenges are real, but the benefits of AI adoption multiply quickly and are a future-forward path to driving down costs for companies and the U.S. healthcare ecosystem as a whole.

Where do you hope to see AI used more widely in the future?

Although there are several areas that could be improved by AI in the US healthcare system, the one area that I hope to see the greatest disruption by AI is payments. Since the rising costs of the healthcare system remains a major concern, we will naturally see a greater willingness from health plans and government agencies to adopt technology that can enable them to reduce costs and improve affordability.

One aspect of this would be to invest in innovative FWA (fraud, waste, and abuse) solutions that help ensure our limited healthcare dollars go to real patient care. We are proud to help the industry move in that direction.

How do you think the healthcare sector is going to evolve in the upcoming years?

The adoption of AI, machine learning (ML), and automation in the healthcare industry is growing. In tandem, healthcare payers, agencies, and pharmacy benefits management are increasing their level of investments in these technologies.

The value proposition is clear: these technologies can deliver transparency across the payment spectrum and create a unified view across claims, providers, and patients for proactive payment integrity. All of this supports Codoxo’s mission of making the U.S. healthcare system more affordable and effective for everyone. Technologies like AI might hold the key.

Share with us, what’s next for Codoxo?

At Codoxo, innovation is one of our core company values and we are constantly looking for new and innovative ways to make an impact to help contain our rising healthcare costs. We have made significant investments in AI and automation over the past couple of years and have been successful in breaking down silos that have existed across various teams within healthcare organizations.

One of the areas we are now focusing on is to include providers as partners in our mission to make the healthcare system more affordable. We have developed new, innovative products that are unlike anything else in the industry which help bring transparency to providers and educate them to maintain compliance with coding guidelines and policies in health plans. This ensures their claims are accurate so they do not get flagged for audits that tend to cause abrasion.

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