Case Study: Leading Health Insurance Company achieves an 87% fraud-hit rate and £98.5M in prevented/recovered payments with Shift Technology's Fraud, Waste & Abuse Detection

Shift Technology helps tier 1 insurer detect and prevent fraud, waste and abuse cases

Leading Health Insurance Company, a tier 1 insurer covering more than 4.5 million people, faced rising fraud, waste and abuse across a complex, merged product portfolio. Existing rules-based systems and siloed data struggled to keep up with evolving schemes, leaving the insurer unable to reliably detect fraud before payment; they engaged Shift Technology and its Shift Fraud, Waste and Abuse Detection to tackle these challenges.

Shift Technology consolidated and cleansed claims data, applied entity resolution and trained AI scenarios to score claims in real time, generating explainable alerts and integrating with payment and case-management systems. The SaaS solution delivered an 87% hit rate for actionable alerts (vs. a 30% industry standard), analysed £19.5B of claims with 4% flagged, recovered £44.5M, blocked £54M before payment, and boosted team efficiency by an estimated 20%, saving the insurer tens of millions of pounds annually.