Case Study: State Medicaid Agency achieves 1,500% ROI in 12 weeks with Codoxo Fraud Scope AI

AI-based Fraud Detection Solution Helped Program Integrity Unit at State Medicaid Agency Realize a 1,500% ROI in 12 Short Weeks

The State Medicaid Agency needed a more cohesive way to detect fraud, waste, and abuse across its fee-for-service program. Its Program Integrity unit was stuck with highly manual processes, limited reporting, siloed workflows, and heavy dependence on IT to produce trend reports, making it difficult to quickly spot current or emerging suspicious provider behavior. Codoxo’s Fraud Scope AI platform was introduced to give analysts and investigators a single view of claims and cases.

Using Codoxo’s Fraud Scope, the agency quickly surfaced new and emerging fraud trends, enabled analysts to create cases, and gave investigators a single source of truth for deeper review. In just 12 weeks, the agency reported more than 1,500% ROI, over $4M in back-billing opportunity, nearly $7M in total risk exposure, and an estimated hard recovery of over $4.7M; one case alone identified nearly $2M in potential recoupment. The success led the agency to expand Codoxo beyond the initial scope to cover facility and dental claims and more than 2.5 million members across multiple lines of business.