Software for Health Insurance Eligibility Detection - SHIELD

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A SHIELD for medical claims automation and fraud, waste, and abuse detection

While underwriting automation is widely implemented, medical claims are yet to be fully automated, despite their large volumes, high frequency, and overall average cost. igital transformation empowers customers to expect instantaneous responses from insurance companies; thus, medical claims automation becomes imperative for their competitiveness.

According to Deloitte1, insurance organizations are under constant pressure to offer improved services at reduced costs, specifically for claims management. However, still, millions of invoices are checked manually to weed out all the unjustified claims. This process is a lengthy, paper-heavy one that requires time, expertise and costs a lot of money. In addition, manual checking does not always discover all the errors in invoices, and decisions can be false.

Real-time Automatic Claim Management

To minimize the risks of such a manual process, MR HealthTech created the Software for Health Insurance Eligibility Detection (SHIELD), a high-performance claims management engine for increased automation and fraud, waste, and abuse detection to health insurers. SHIELD checks automatically the medical plausibility of invoice items and instantly identifies incorrect invoices.

Key Features

Medical Plausibility

SHIELD is a configurable system that easily integrates into the health insurer's existing IT landscape and workflow. During the Authorization and Claims processing, created through either manual insert or automatic import, SHIELD evaluates each Invoice Line against the system’s full spectrum of rules.

It then determines whether an invoice is reasonable and appropriate from a medical viewpoint, and provide a result for each rule, informing the user about each decision’s reason.

Powerful Cost Containment

Along with the medical rule types, SHIELD also incorporates historical rule types to recognize contradictions from already settled claims data and cross-check the current medical circumstances. For example, if a Once-in-a-Lifetime (OLT) procedure was performed on a patient at an earlier date, the same OLT procedure billed now is automatically rejected by the system.

Also, Outlier Detection rule types in the system provide cost containment. For example, if a surgical procedure has a minimum value of 1,000$ and a maximum value of 3,000$, any benefit submission outside this price range will trigger the rule.

It works either stand-alone or integrated with any insurance back-office system enabling even legacy technologies and operations to become more agile and efficient.

Key Benefits

SHIELD will allow you to:

  • Reduce the turn-around time
  • Increase client satisfaction
  • Reduce the risk of fraud, waste and abuse cases
  • Increase the automatic adjudication of claims reducing the cost
  • Provide transparency and consistency in the claims' adjudication

Higher clear-up rate within a shorter period

Multiple pilots and PoCs over the past two years have shown that SHIELD increases the claim processing automation between 20% and 30%. This result translates into faster and more straightforward claims assessment and processing. Working more effectively with SHIELD, the claims assessors spend less time reviewing large numbers of claims and instead focus on investigating inconsistent claims.

Learn more about how SHIELD can automate your claims process by sending us an email at

1Deloitte – The future of insurance claims management article (