The healthcare payment workflow is complicated by multiple specific claims codes, evolving policy, plan guidelines, and some claims requiring medical records for validation. Errors, whether accidental or potentially fraudulent, often hinder this process, resulting in
improper or unnecessary payments and abrasion within provider networks. Health plans face labor shortages, which complicate the claims review process, causing long backlogs in claims reviews and leading to significant unneeded payments. The National Health Care AntiFraud Association estimates that about 3% to 10% of the total healthcare expenditures are due to healthcare fraud, waste and abuse equating to over $300 billion lost annually.
Founded in 2014 with a singular focus on insurance, Shift Technology (Shift) leverages its deep artificial intelligence (AI) and data science expertise, giving payers tools to enhance claim and payment accuracy. Its generative AI (GenAI) and AI tools perform data curation and analysis enabling customer-specific prompt engineering to accelerate medical record reviews, optimize claim edits, and detect possible fraud, waste and abuse (FWA), presenting clients with enhanced claims and payment accuracy. Moreover, the company’s payment integrity solutions provide explainable, transparent results, providing clients with the context and analysis to drive decision-making or investigations. Shift’s highly accurate and closed-loop product strategy enhances health plans payment accuracy, decreases wasteful or potentially fraudulent claims payment, and aids in identifying provider education opportunities to enhance long-term payment accuracy. As a result, the company has analyzed over three billion policies, claims, and documents, identifying hundreds of millions in savings opportunities for plans.
