Shift Fraud, Waste, and Abuse Detection/Improper Payment Detection

Shift Fraud, Waste and Abuse/Improper Payment Detection provides a high-impact, AI-native approach to identifying fraud, waste and abuse for health plans. By leveraging enhanced data and artificial intelligence, the solution provides insights investigators need to maximize savings and recoveries. It gives other users within health plans the ability to analyze behaviors and actions across multiple lines of business—individual providers and provider networks, third parties, plan members, and more.

FWA Key Features:

Internal and External Data Integration

Sophisticated data cleansing and mapping that consolidates relevant claims and policy data using data quality routines, denoising algorithms, entity resolution techniques, and health insurance-specific models to ensure data quality.

Integrated external data sources including publically available official records, data aggregators, provider and other business consumer review and social media data.

Insurance trained AI/ML models and sophisticated predictive analytics

Automatic anomaly detection and natural language processing of text variables.

Continuous-learning AI/ML models designed to uncover complex fraud and increase accuracy of alerts at the prepayment and post-payment level

Member focussed scenarios to detect eligibility, change of story, pre existing conditions, false beneficiary information and much more

Provider fraud, waste and abuse detection scenarios covering duplicate and erroneous invoices, ghost sessions, upcoding and much more

Network and collusion discovery and analysis

Network link analysis to uncover unknown linkages or relationships among seemingly unrelated claims, providers and members

Interactive network visualisation allowing investigators to explore network nodes, exploring relationships, interrogate relationships and add notes

Investigator dashboard with detection results, alerts and full context

Prioritised alerts at the Claims, Member, Provider and Network level with clear scoring and supporting alert and investigative information

Configurable investigator dashboard detailing key information regarding the alert including the projected value

In depth alerts detail, showing all attributes and characteristics that have led to the alert score, links to external and internal information found to be relevant and recommendations of next investigative steps.

Reporting

Custom data exploration and reporting including dashboards showing alert detection, qualification and conversion rates, team workload, trending and scenario performance

Confgurable filtering and display

Case management and workflow

Integrated case-management features for task assignment, team management, communication and collaboration

Document and correspondence management for requesting and storing medical records, patient consent and instructing internal teams

Rapid deployment and dedicated team of Shift experts and DS

Options to run scenarios in batch or real time, real time alerts investigators prior to claim settlement allowing payments to be blocked if necessary.

4 months average implementation time frame with rapid time to value and ROI

Continuous scenario performance monitoring with dedicated Shift DS and CSM teams and where needed scenarios are further fitted to client data to further improve detection and recovery success

Using a SaaS model, the Customer Success Manager, the Shift Data Scientist, and Shift FWA detection’s ML algorithms continually update fraud scenarios to stay current with evolving fraud trends and emerging schemes

FWA Benefits:

Reduce investigation time and lower costs

Save teams significant manual inspection effort and fact gathering with the Shift platform data extraction of key facts from unstructured data. Customer report between 20 and 50% reduction in investigation effort.

Remove reliance on medical experience, basic rules, gut feel and rudimentary prioritisation by leveraging pre trained ML scenarios to match conditions/treatments and prices.

Reduce investigation cycle time from months to weeks as the Shift platform and UI integrates and unites multiple structured and unstructured data sources, delivering full context directly to investigations.

Find more fraud

Stop up to 9 Euro leakage per member and get instant insights across all transactions covering both member and provider cases, illuminating networks, relationships and collusions.

Find previously undiscovered complex and major cases with Shift Network Detection, as Shift assimilates collusions and relationship maps in seconds savings customers millions of pounds a year in addiitonal fraud savings.

Gain the ability to accurately analyse and check all invoices and claims for FWA at source rather than having to manually triage a long list of potential cases filtered by simple rules potentially missing frequent low value FWA.

Increase growth

Gain competitive advantage through delivering even better patient care and providing improved service to genuine members

Elevate processes in order to prepare for increased policy uptake and claims volumes, to leverage global PMI trends

Reduce audit and recovery effort

Accelerate case workflow and recovery and increase team efficiency with Shift Case management to automate consent and recovery tasks

Consolidate documents, records, audits and reports for each case easing collaboration and saving teams effort

Ensure great patient care

Fast track genuine claims and deliver great patient care as Shift scenarios alert and block suspicious cases in real time, routing them to the correct investigation team and away from triage

Prevent leakage and remove cost immediately from the bottom line as Shift scenarios automate checks on every claim and invoice alerting investigators before incorrect payments are made.