The Situation
A large national health plan covering 1.5 million Medicare lives sought a renewed savings strategy to keep premiums affordable for its members. As a secondary payor to Medicare, the plan faced increasing pressure to improve payment accuracy and operational efficiency. Existing processes were falling short of payment integrity expectations, and the plan needed a solution to deliver measurable financial savings.
The Solution
Shift partnered with the health plan to implement an innovative, AI-powered claims editing solution focused on maximizing prepayment savings. The engagement began with a pre-production edit workshop and testing phase, demonstrating the value and impact of specific edit types and tailoring the claims editing strategy to the plan’s unique needs.
Key Functionalities
- Intelligent edit selection: Leveraging plan data, financials, and operations to prioritize claim edit types and optimize specific edits.
- Pre-production analysis: Edit workshop & analysis on realtime prepayment data proving the value of targeted edits and confirming appropriateness to turn on edits.
- Cross-claim analysis: Uncovering deeper insights and issues at the claim level that traditional editing solutions often miss, further increasing accuracy and efficiency.
- Automated processing: Automated intake of claims data, followed by analysis and automated delivery of reason (CARC & RARC) codes with transparent and explainable context, and flexibility to adjust on how the plan responds to edits.
The Result
Within one week after go-live, Shift’s solution identified over $100,000 per day in prepayment savings opportunities for the health plan. As a first-pass claims editor for a secondary payer, the solution delivered immediate and ongoing financial impact.
$100,000
per day in identified savings
Shift accelerated the time to value for this health plan; finalizing complex data mapping, edit selection, testing, deployment, automation and user onboarding in just under 4 months.
“With the current progress and findings since go-live, we’re confident Shift can save up to $40 million a year for our plan.”
— Current Health Plan Actuary
By automating and enhancing the plan’s primary claims editing, the health plan achieved significant operational efficiencies, improved payment accuracy, and reduced provider abrasion—demonstrating Shift’s commitment to innovation and measurable results.