The Corruption, Misuse and Consequences of Fraud, Waste and Abuse: Part 2

by Tonya Veltman

In Part 1 of her piece on Fraud, Waste, and Abuse (FWA) trends in the healthcare industry, Shift Technology Customer Success Manager Tonya Veltman explored  what FWA is, why people may feel compelled to commit it, and how it may get spotted. In Part 2, she looks at the specific ways Shift can help payers mitigate the problem.

How Exactly Does Shift Help Payers Spot Fraud, Waste, and Abuse in the Claims Process? 

At Shift we have automated the level of expertise that comes from the experience and knowledge already found within an insurance company’s employees, and we apply it alongside the existing insurance data to make decisions across the claim lifecycle. 

In fact, Shift Improper Payment Detection allows health payers to extend beyond the typical Fraud, Waste and Abuse (FWA) detection methods available in the market by generating tips and scenarios that assist the claims and SIU teams to:

  • Identify increased volumes of potential fraud, waste and abuse
  • Reduce financial loss as a result of fraud or improper payments
  • Provide a better focus in terms of claims handler work efforts
  • Improve efficiency within claims processing and the investigation life cycle
  • Shorten decision making turn around times and thus improve the customer service experience
  • Ensure valid claims are paid quickly and efficiently at first pass
  • Engage other departments which may be better suited to address an issue (e.g. provider relations or contracting)

Overall, the advantages of Shifts fraud detection capability and tools are clear.  

The Approach Behind Detection?

Shift leverages large amounts of data collected from both internal and external/third-party party sources to detect instances of improper payment. Using this data along with the learnings shared by the insurance company’s investigator or claim handler’s knowledge and experience we can effectively identify large, complex fraud patterns; instances where provider utilization appears skewed; or even instances where legitimate claims were denied and should not have been.

Because Shift only services the insurance industry and more than 30 percent of employees are data scientists who are responsible for ensuring the successful configuration and optimization of the solution specific to each client/insurer, we are incredibly well suited to help payers meet their challenges head on. This includes reacting quickly to evolving trends and increasing the value of the solution by providing regular support and updates to the models and scenarios used to spot improper payments..

Shift provides detailed and data driven guidance aimed at identifying improper payments by integrating both internal and external data into the model and turning the data into actionable tips, scenarios and opportunities to obtain results.

By applying a new technology approach to truly meet the needs of health payers, Shift is changing the way the industry thinks about tackling the problem of fraud, waste, and abuse.

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