Shift Improper Payment Detection Addresses $100+ Billion per Year Challenge Facing Health Insurers

by Shift Technology

Latest Technology in the Shift Insurance Suite Gives Health Payers New Tools  to Better Mitigate the Impact of Fraud, Waste, and Abuse

PARIS and BOSTON – June 8, 2021Shift Technology, a provider of AI-driven decision automation and optimization solutions for the global insurance industry, today introduced Shift Improper Payment Detection. The newest product in the Shift Insurance Suite, Shift Improper Payment Detection is designed to give health insurers not only an understanding of the Fraud, Waste, and Abuse (FWA) impacting the business but also visibility into provider and member networks to increase provider quality scores and deliver quality care to each patient.

Traditional approaches to FWA typically focus on identifying payments that should not be made – either prospectively or retrospectively – and are driven by individual alerts delivered to a Special Investigative Unit (SIU). While this approach can be effective in spotting individual instances of suspicious claims, its narrow scope does little to provide insight into potential problems in the plan’s provider network, nor does it help identify possible issues related to members’ quality of care. Shift Improper Payment Detection differentiates itself by delivering actionable insights centered on a holistic claims lifecycle approach that helps plans spot suspicious claims based on continually updated scenarios; suspicious relationships within provider networks; suspicious member behaviors; anomalies in care delivery that may impact the patient experience; and opportunities for training and education.

“Healthcare is a complex industry that has a deep impact on everyone’s life and well-being. Getting all the market participants – including healthcare providers from both the private and public sectors, insurers and payers – together to optimize medical services for the insured is a noble cause,” commented Nicolas Michellod, Celent. “In this context, Shift Technology’s proposition to help health insurers improve member quality of care, promote provider behavior modification and identify improper payments contributes to generating more value from their health ecosystem.”

Shift Improper Payment Detection is an automated solution that enables health insurers to detect and prevent improper payments using the combined power of advanced AI, Business Intelligence (BI) logic and process automation. It enables users from a variety of teams within a health insurance organization to analyze behaviors and actions across multiple entities — individual providers and provider networks, third parties, plan members, and more. Through this new model payers can uncover a greater number of improper payments and better understand the impact on the plan and its members, including:

  • Member Quality of Care – Shift Improper Payment Detection can identify claims that are improperly paid, including those paid when services are not rendered, which can negatively impact the member. (e.g., a diagnosis of mental health). The plan can correct this once identified.
  • Provider Behavior Modification – Shift’s approach to improper payment detection creates a feedback loop which empowers the plan to intervene from a provider network/contract perspective to change behavior.
  • Improper Payments – Shift Improper Payment Detection not only identifies not only suspicious claims but also improper payments that negatively impact the bottom-line. An “Actionable Insights” approach to alerting helps ensure operational efficiency.

“The health insurance industry understands that fraud, waste, and abuse does not just impact the business, but also its members,” stated Marcel Gordon, vice president, Product, Shift Technology. “With Shift Improper Payment Detection, we are giving health insurance provides a powerful new solution that holistically addresses the problem while at the same time improving member outcomes.”
 
Shift Improper Payment Detection is initially available to providers doing business in the United States.
 
About Shift Technology
Shift Technology delivers the only AI-native decision automation and optimization solutions built specifically for the global insurance industry. Addressing several critical processes across the insurance policy lifecycle, the Shift Insurance Suite helps insurers achieve faster, more accurate claims and policy resolutions. Shift has analyzed billions of insurance transactions to date and was presented Frost & Sullivan’s 2020 Global Claims Solutions for Insurance Market Leadership Award. For more information, please visit www.shift-technology.com.

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Contacts:

Rob Morton
Corporate Communications
Shift Technology
+1.617.416.9216
rob.morton@shift-technology.com

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