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Healthcare Improper Payment Detection

Break out of the confines of rules-based detection

Healthcare Improper Payment Detection

Fraudsters certainly aren’t playing by the rules - your detection strategy shouldn’t either. Designed to go beyond traditional rules-based detection methods, Shift Improper Payment Detection uses enhanced data, combined with healthcare-trained AI models to uncover 4x more fraud, waste and abuse, increase detection accuracy and boost the efficiency of investigators.

  • Combines claims data and 100+ external data sources for real-time AI analysis that identifies potential improper payments with speed and accuracy
  • Dynamic, prioritized alert scoring for high-value prepayment and post-payment detection
  • 100% explainable alerts, with context and supportive documentation to empower investigators
  • Integrated case management for a seamless, efficient workflow without having to leave the platform

Impact:

Transform claims and external data into actionable, investigative insights - increasing the efficiency of the SIU by 200%

Increased Accuracy
Increased Accuracy

Identify suspicious claims, providers and third parties based on continually updated scenarios.

Faster Investigations
Faster Investigations

Explainable AI provides decision recommendations tailored to the needs of users throughout the healthcare insurance organization.

Reduced Cost
Reduced Cost

Prioritize the largest cases to maximize savings and recoveries.

Improved Efficiency
Improved Efficiency

Easily access external data and manage case workflow all in one platform.

Prioritized Alerts & Contextual Guidance

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A 360° View in a Single UI
Integrated internal and external data sources, provider snapshots, utilization details and more all in one place
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AI-Powered Alert Scoring
Increase alert accuracy with continuous learning AI models identifying and scoring suspicious activity
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Go Deeper with Network Analysis and Related Providers
Uncover relationships between providers, members, facilities and more
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Integrated Case Management
Case qualification, task assignments, notifications and e-mail capabilities without ever leaving the platform

Let's work together to transform insurance decision making!

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