Dr. Musheer Ahmed is the CEO and Founder of Codoxo. He founded Codoxo (formerly named FraudScope) to help make our healthcare system more affordable and effective. Codoxo’s Forensic AI Platform uses patented technology to identify problems and suspicious behavior earlier than traditional techniques, which helps ensure our scarce healthcare dollars go to real patient care. Dr. Ahmed developed this technology as a part of his 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 his doctoral research tackled some of the biggest challenges within the emerging health data infrastructure in the United States. Several media outlets have interviewed Dr. Ahmed for his work in reducing healthcare fraud, waste, and abuse. When he’s not fighting healthcare fraud, you’ll find him volunteering for various causes and spending time with his family.
What You’ll Learn In This Episode
- About Musheer’s background
- About Codoxo
- The types of fraud schemes Codoxo’s AI is uncovering
- AI evolving to help reduce costs in U.S. healthcare
This transcript is machine transcribed by Sonix
Intro: [00:00:03] Broadcasting live from the Business RadioX Studios in Atlanta, Georgia. It’s time for Atlanta Business Radio, brought to you by on pay. Built in Atlanta on pay is the top rated payroll and HR software anywhere. Get one month free at unpaid. Now here’s your host.
Lee Kantor: [00:00:31] Lee Kantor here, another episode of Atlanta Business Radio. And this is going to be a good one. But before we get started, it’s important to recognize our sponsor on pay. Without them, we couldn’t be sharing these important stories. Today on Atlanta Business Radio, we have Musheer Ahmed with Codoxo. Welcome Musheer.
Musheer Ahmed: [00:00:50] Thank you, Lee. Happy to be here.
Lee Kantor: [00:00:52] Well, I’m excited to learn what you’re up to. Tell us a little bit about Codoxo. How are you serving folks?
Musheer Ahmed: [00:00:57] So at Codoxo, our goal is to make the health care system more affordable and effective for everyone. At America, we spend more on health care than any other nation in the world today. Unfortunately, not all of that money is going to real patient care a significant amount. According to some estimates, 3 to 10% of health care expenditure is lost to fraud, waste, and abuse in the healthcare system. And despite these losses being an order of magnitude higher than other industries, we’ve seen very little innovation happen in this space compared to those industries, with reports saying that only a fraction of that fraud, waste, abuse is currently being identified by these products. So this is the core issue that Codo xo is helping identify and addressing this major fraud, waste, abuse problem in the health care today.
Lee Kantor: [00:01:49] So what are some examples of fraud, waste and abuse in health care?
Musheer Ahmed: [00:01:53] So that’s a great question. So fraud, waste, abuse and sometimes people put an error is actually a spectrum of payment issues in health care. So fraud is defined by those things that are provider and typically it’s mostly providers more so than members may engage intentionally in deriving certain payments that they may not be eligible for or authorized to get. Let me give you an example. Let me start off with the most egregious ones. For example, there was a provider, an oncologist in Michigan, who said almost all his patients had cancer, put them through chemotherapy. But it was later identified that a majority of his patients never had cancer to begin with. But he engaged in that process, ruining those people’s lives just so he could file over $30 million in insurance claims and and just become rich. So that’s a very egregious example. Another example of pure intentional fraud is fictitious claims. So fictitious claims. An example of that is a phantom clinic, which is a clinic that does not exist in real life. It could just be a UPS mailbox address that looks like a real street address, but they still provide their identities, patient identities, file claims for maybe 4 to 6 months for 10 to $20 Million, and then shut down that clinic, move to another state and repeat that process.
Musheer Ahmed: [00:03:19] So that has been prevalent for a while in the past, and that’s an example of fictitious claims. Then you have waste and abuse, which is not as bad, but you’re looking at procedures that are maybe medically unnecessary. They are not providing any benefit to the patient. Or maybe you’re you’re prescribing brand name drugs that are very, very expensive. When there is a generic alternative that is much more economical, that’s equally effective, causing wasteful expenses into the health care system. So that, I would say, are examples of the entire spectrum of fraud, waste, abuse that exists in this space. And Lisa, the National Health Care Anti-Fraud Association estimates the 3 to 10% figure that I mentioned to you earlier, and we know last year we spent almost 4.2 or $4.3 trillion on health care. So that 3 to 10% translates to hundreds of billions of dollars lost every single year in the US to this problem which which affects every individual paying more than $1,000, then they should be on the health care that they’re receiving.
Lee Kantor: [00:04:34] And when you’re describing all of this fraud and abuse, it it sounds like it’s never the the patient. It’s always the clinic or some scammer that’s that’s taking advantage of the patient.
Musheer Ahmed: [00:04:49] So the patients do engage in fraud, waste, abuse as well. But in terms of the financial impact, it is driven significantly by providers, which would be physicians or are facilities, etc.. So they are definitely causing more of an economic impact and financial impact to this problem as opposed to members. Members do engage in that, but the financial impact is largely not driven by them.
Lee Kantor: [00:05:19] And then Cardiaco solution is to use artificial intelligence to uncover some of this fraud.
Musheer Ahmed: [00:05:29] Yes. So I come from an academic background. So I received my PhD at Georgia Tech and my PhD was focused around developing sophisticated AI based technologies to help address this problem. So this problem has been going on for a long time, and we at Georgia Tech love to find hard problems and try to solve them, which is what got me really, really excited and interested in this space. And the root of the issue is that fraud, waste, abuse teams are constantly evolving. The major schemes that are happening today are very different from the major schemes of, let’s say, last year or maybe even two years ago. They’re constantly changing. However, the detection capabilities were largely static and they were really good at finding schemes we’ve seen in the past and maybe a few schemes some experts had predicted, but they weren’t really proactive in identifying what’s the new scheme that fraudsters are coming up with so we can stop bleeding and minimize the financial impact very quickly. So what would happen is a new scheme would come up today and that would go on sometimes for months, in some cases even years bleeding. We have organizations in millions or tens of millions of dollars before someone would stumble upon it and take action. So our goal at Georgia Tech, which formed the basis of the core technology at products today, was we want to develop a proactive AI capability that’s able to identify new schemes as quickly as they emerge, give that intelligence to our customers, allow them to take action to minimize the financial impact by stopping the bleeding very quickly. And that’s the core basis of what we do really, really well. But of course, since then, we’ve we’ve had a ton of impact. We’ve already helped our customers save over $500 million, which we’re really proud of.
Lee Kantor: [00:07:21] Now, how is this problem different than like kind of some of these cybersecurity problems where you’re trying to identify hackers or schemers that are trying to infiltrate a business to do something nefarious? Is it similar? Are the bad guys similar in that? In some cases in that area, they’re nation states because there’s so much money involved? Or are these individual just bad guys that have found a way to, you know, make money by exploiting the health care system?
Musheer Ahmed: [00:07:53] That’s a great question, Liane. Actually, so my PhD at Georgia Tech has actually in the cybersecurity space and I took a unique, unique path of focusing my entire dissertation in health care. Even though I was a part of the cybersecurity department and a lot of the ideas that I’m bringing into the health care space and put out so continues to work on and bring to our customers that are really, really unique, are actually founded in the cybersecurity space. And you’re absolutely right, we in the cybersecurity world are always trying to keep up with evolving threats. But there are certain things about health care that make it really, really different. And so just to take an example in general, comparing health care not just to cybersecurity, but other industries in general, their health care payments tend to be really, really complex. It’s a it’s a complex system that we’ve evolved over time. And sometimes we need to make a decision without having all all the data points necessary and all the data points that may be able to influence the payment. To give you some examples of that, you may have medical records that can influence what should the actual allowed payment be. You may have contracts that are not standardized with providers that may also cause variations in payments.
Musheer Ahmed: [00:09:10] And you may need we need to make a decision in health care at the payment point without necessarily having access to the medical record or having access to even the contract information. So their decisions that need to be made really, really quickly, there’s no standardization and how certain things may be paid across different providers just based on different issues the member may have been facing with. The other thing that is very unique about the health care space is what is the impact of a false positive. Now let’s say you’re and just to compare simplistically, you look at the credit card space, you deny a transaction, what’s the worst thing that’s going to happen? The cardholder is going to try the card again or use another card in healthcare if you deny payment. Now, that could lead to significant issues and in some cases you may even end up in court because of something that you care that you may have denied a member. So the stakes are higher, the data points are fewer, the complexity is greater. So it’s it’s a much more challenging problem to solve in the healthcare space.
Lee Kantor: [00:10:16] But but when it comes time to for payment, like usually if I’m paying something on my credit card, it’s happening at that instant. But in health care, if I’m paying something, it could be a year after I had that treatment.
Musheer Ahmed: [00:10:29] That’s absolutely correct. So it’s the claim itself. I think there is a time period within which the provider will submit a claim to the health plan. Once the health plan receives the claim, there is the they are laws that require the claim to be paid. But unfortunately, the system doesn’t operate in as real time a manner as it should, and which is actually very indicative of the lack of adoption of new technology in the healthcare space. And health care has unfortunately not adopted not just those kinds of real time processing capabilities, but even the AI capabilities. We were the pioneers of bringing AI into this space. And since then, then the impact we’ve been able to show with the savings we’ve been able to bring to these clients, the industry has now started asking for AI capabilities. Now health plans understand the value and other players have been asked to also bring the AI capabilities into this space. So your you’re hitting spot on on something that’s been very common in health care, the lack of adoption of new technology. But we are really proud of that product. So to lead the way to show the industry on how they should be operating, we’re hoping at some point we do get to real time payments and health care, but we are a long way off now.
Lee Kantor: [00:11:51] Today, they’re now using AI to reduce costs by, you know, kind of sniffing out the fraud as it’s happening or as quickly as possible is obviously that saves money. Has the AI evolved to the other side of the equation to help, you know, identify illnesses faster or to be able to make diagnosis quicker?
Musheer Ahmed: [00:12:17] There are there are a lot of AI initiatives. And what I would say is, even though the industry has been reluctant to bring about AI in most areas and just adopt new technology in general, I think COVID became a catalyst for the healthcare industry to really take a look and understand, okay, how do we need to change? There were a lot of things, a lot of pressures that were put on the health care system. And I think that mindset is slowly changing now. And there are a lot of AI initiatives that are actually gaining a lot of traction and spotlight and attention. They are several initiatives just focusing on what you just described on the ability to find diseases faster. There’s a lot of A.I. companies that can help. For example, just to give you a quick example, look at radiology scans and predict, okay, this person is going to land with some kind of disease in the future. That may not be very, very prevalent in that radiology scan that you may be looking at. So I think there’s a ton of work going on. The industry is heading in the right direction, but just not fast enough compared to where the level of adoption you’ve seen at other places.
Lee Kantor: [00:13:31] Now, it sounds like it’s a in some way it’s a dangerous area. Like if if I can predict this person is going to potentially down the road have some problem, then I can increase their insurance now knowing that ahead of time that I’m going to have to pay out. Like how does that all play together? Because that seems really murky.
Musheer Ahmed: [00:13:55] Yes, that is that’s definitely they are going to be some gray areas, Ali. And of course, a lot of times government influences on what can and cannot be done, such as the preexisting conditions, actually impact your insurance premiums or not, or are they covered or not? So I think they will be a role that the government may play in regulating some of these things. But you’re absolutely right. I think as this technology becomes more sophisticated, they are they are things that we need to manage better going forward.
Lee Kantor: [00:14:36] So what’s next for Oxo? How can we help?
Musheer Ahmed: [00:14:39] So Cardoso. So I think we’re really excited about the impact we’ve had so far. Class research just did an independent study on our customers and they gave us an A-plus rating. 100% of our customers would buy again and would recommend to others. We are even more excited about what we can do in the future and the impact we can actually have in this space. We’ve actually come about with new innovative products that just don’t exist in this space. So two of them that I’ll quickly mentioned here, one of them is provider scope, which is our ability to engage and collaborate with providers in helping make the health care system more affordable and effective. So we give providers an early warning system so they can proactively change their own behavior, ensure they are following the coding guidelines and CMS guidelines on claim submission so we can weed out a lot of costs that were caused due to incorrect coding or even audit code that helps automate the workflow and bring about the level of efficiencies that we haven’t seen in this space today. I think I’ve put actually we’ve doubled our headcount over the last 12 months. We continue to add people who are really mission driven and really care about our goal of making the health care system more affordable and effective. So if there’s anyone listening who would like to really make an impact in the health care space, we’d love to have you on our team. Definitely do reach out to us and we’d love to have a conversation. And if there are plans out there that would like to engage with us, we work with health plans. We work with government agencies and also in the pharmacy benefit space. Now, if you’d like to use our technology and bring about the kind of results so we are able to bring about, we’d also love to hear from you.
Lee Kantor: [00:16:31] Well, thank you so much for sharing your story today. You’re doing such important work and we appreciate you.
Musheer Ahmed: [00:16:36] Thank you so much, Lee. I appreciate it.
Lee Kantor: [00:16:38] All right. This is Lee Kantor. We’ll see you next time on Atlanta Business Radio.
Intro: [00:16:45] Today’s episode of Atlanta Business Radio is brought to you by on pay. Built in Atlanta, on pay is the top rated payroll in HR software anywhere. Get one month free at paycom.