Covered began as a services business (fighting denials in exchange for a percent of what we recover) and has now developed a software product that we are licensing based on our experiences fighting denials and feedback from RCM professionals. Covered can generate appeal letters, and helps RCM specialists fight and prevent denials by layering AI on top of previously diverse and unconnected databases (medical policies, FDA guidelines, LCD's, etc.). This allows them to identify denial root causes, and is used pre-submission and post-denial. We have paying customers and have been around for nearly two years.

Payers constantly change the rules. Sift evens the playing field. Sift equips healthcare organizations to fully leverage their payments data to work smarter, protect their margins and accelerate cash.

Actionable Denials Intelligence, delivering a longitudinal view of clinical, coding, claims and remittance data. Sift establishes a data foundation that gives providers unprecedented access to their payments data and intelligence tools to better manage their denials, identify root causes and prevent future denials. 

• Unified, normalized and organized claims and remittance data.
• Delivering an accessible and complete picture of claim behavior, payer trends and the drivers of denials.
• Curated, consultative analysis pinpointing where your team can take action to prevent denials and optimize workflows.

Denials Prioritization & Intelligent Automation to better manage touches and lower the cost of delivering each dollar of cash.

• Sift’s machine learning optimizes workflows by prioritizing your team’s denial work efforts around ROI and by delivering Smart Claim Edits that improve first-pass yield. 
• Active-Learning Claim Scrubber analyzes daily claims and remittances to curate high-impact claim edit recommendations.
• Machine learning models that score denials at an atomic claim level, using over 500 attributes to determine each denial’s likelihood to overturn.
• ROI-based denials worklists seamlessly integrate into your EMR, prioritizing high-recovery denials in staff workqueues.
• Scoring that enhances existing automation capabilities, enabling the strategic automation of low-yield accounts while avoiding over-automating recoverable accounts.

Denials Prevention. By unifying clinical, coding and payments data, Sift's ML predicts denials before claims are created and provide recommendations for upstream interventions. 

Sift’s ML models predict the likelihood of denial and provide pointers for intervention and prioritized user analysis, working to optimize payment outcomes.

• Machine learning models score encounters around their likelihood of being denied, proactively flagging encounters for intervention before claim submission.
• Denial category prediction and root causes pointers enable routing to the appropriate mid-cycle workflow for mitigation.
• Mid-Cycle Denials Intelligence that ties back-end billing, denial and overturn patterns to upstream workflow data inputs to deliver root cause analysis and prevention recommendations.

Denial Prevention tools: Approximately 50% of denials can be prevented, but even if you send "cleaner claims", you’re beholden to the next algorithm shift that (often incorrectly) automates denials. What about the 50% that are not preventable, where you've done everything right? 

Incumbent RCM software companies: Move slowly, denials not a core focus area, and with older solutions, the tech is not easy to use or modern. Our sole focus is excellence in the prevention and addressing of denials. 

New Entrants / Direct Competitors: Very new, and in a fragmented physician market, there are billions of dollars in denials to attack. Most importantly, while these are also based in AI/LLM's, our focus is on truth. What does the payer say they will cover, and how does that match up to what was done? This is a key differentiator.  

1. ML to predict propensity-to-overturn, enabling dynamic denial prioritization -- rather than rules-based systems (i.e. EMR offerings).
2. ML to predict propensity-to-deny, enabling denial prevention before claims are created. 
3. Rev/Track Insights Reports with curated intelligence and action items.
4. Unified and accessible data foundation, including:

• Matched claims and remittance data
• Unified and normalized payments data
• Payments data matched to corresponding CDI and coding data.