“Do more with less.” Health plans are expected to improve claims and payment accuracy while keeping administrative costs low - all while managing constant change in care delivery, policy updates, and technology advancements. It’s a tall task. In its latest report, Reshaping Payment Integrity Solutions: Specialists Creating Buzz in the Market, Everest Group outlined and hit home those industry pressures and showed how current vendors are taking on that challenge in partnership with plans.
As part of this report, Everest evaluated more than 50 vendors across areas such as domain expertise, technology & AI capabilities, and talent, and recognized Shift Technology as one of the Top 10 High-Potential Payment Integrity Specialists. Everest’s research highlights companies reshaping payment integrity through measurable accuracy, automation, and transparency - all essential areas as plans modernize their PI operations.
These same qualities are driving a broader transformation: AI is reshaping how payment integrity gets done. From identifying errors due to overlooked policy to lightning-fast document analysis, or uncovering unseen trends, AI is powering faster, smarter, and more impactful outcomes across the entire claims lifecycle.
AI powered data mapping, cleansing and enrichment ensures plans have the clearest view of activity, and models have the best source of data for stronger AI decision making. Utilizing denoising models for data cleansing, entity resolution models for reconciling duplicate or fragmented entities, or NLP/OCR to structure unstructured data sources give downstream models a step ahead.
Shift is growing prepay savings by 40% through optimizing edits and improving policy adherence with generative AI. Using both supervised and unsupervised learning, Shift analyzes historical claims data to pinpoint high-cost or high-risk areas, helping focus strategies on strengthening existing edits or design new edits or concepts for data mining. Shift dives deep into policy gaps or oversight using NLP/OCR for structuring unstructured policy documents, and takes it one step further with Generative AI capabilities to create new edits out of policy, guidelines, extracted codes and additional context.
Shift is taking weeks of manual review to hours with AI - reducing review times by 80%. What traditionally takes days to weeks of review time can be cut down to minutes or hours with AI. OCR & NLP capabilities are used to extract and analyze unstructured data such as diagnosis codes, procedure codes, claim notes and other medical record content. Generative AI then understands and analyzes unstructured medical records to flag and highlight points of medical records where certain procedures may not be supported by a respective record.
Shift is increasing FWA finding values by 70% with AI - uncovering unknown schemes and expanding findings through network detection. Supervised learning models create detection benchmarks for predictive detection variables based on past member or provider behavior - uncovering outlying or anomalous patterns that may alert potential FWA. To expand findings beyond a single provider or claim, AI-powered network detection uncovers potentially suspicious connections between providers, members, facilities, or other entities based on shared patients, addresses, phone numbers, business data, and external sources. This helps plans quickly identify organized activity or emerging schemes that traditional rules-based systems often miss. OCR and NLP models transform scanned documents, medical records, and supporting documentation into data that is then analyzed for inconsistencies, anomalies, or potential manipulation or fraud - enabling faster, more precise detection of improper activity.
Trust and transparency are critical to an AI-powered payment integrity strategy. Shift’s explainable AI approach ensures every flag or recommendation is supported by clear reasoning - helping payment integrity teams defend decisions or appeals confidently to providers, auditors, and regulators.
Unlike static rule based approaches, Shift’s AI continuously learns from new data, policy changes, and provider feedback. Generative AI automatically extracts billing rules from updated policies and generates new claim edits - keeping plans current with regulatory and coding updates.
As AI becomes more critical in payment integrity, differentiation will depend on how effectively it drives impact and workflow improvements with accuracy, explainability, and trust. Shift’s recognition by Everest Group reflects that direction - measurable, clear outcomes powered by transparent AI. Read the press release to learn more about Shift’s recognition by Everest Group.