Case Study: Harvard Pilgrim Healthcare Improves Fraud Detection with Codoxo AI

Harvard Pilgrim Health Care Embraces Artificial Intelligence From Codoxo To Detect FWA Issues

Harvard Pilgrim Health Care, a leading not-for-profit health services company serving more than 3 million members, wanted a better way to detect fraud, waste, and abuse after becoming frustrated with the high volume of false positives from its traditional rules-based system. The team evaluated newer AI vendors to understand what artificial intelligence could deliver versus legacy fraud detection tools, and selected Codoxo’s AI fraud detection solution.

With Codoxo, Harvard Pilgrim Healthcare implemented an AI-driven fraud detection engine to run alongside its internal reporting tools and identify claims and provider behavior that appeared abnormal. The solution helped surface problematic providers based on coding practices, delivered far higher-quality fraud leads than the old rules-based approach, and improved the team’s ability to spot emerging fraud schemes before they became widespread.

Harvard Pilgrim Healthcare

Brian Robinson

Director