Highmark Makes a $220M Impact in the Fight Against Healthcare Fraud, Waste and Abuse in 2020

Highmark’s Financial Investigations and Provider Review (FIPR) department generated more than $220 million in savings related to fraud, waste and abuse in 2020, and has made a cumulative financial impact of nearly $1.1 billion in such activity since 2015. By deploying sophisticated artificial intelligence programs and partnering with health systems, public health officials, law enforcement and other health stakeholders, FIPR is protecting Highmark customers and ensuring health care dollars are spent on high-value care.
 
Highmark prevented significant fraud, waste and abuse across its lines of business in 2020. That includes nearly $130 million in savings related to employer-based health insurance, $50 million from the Blue Card program (which provides Highmark customers with access to national Blue Cross Blue Shield networks), $22 million from Medicare Advantage, $9 million from the Affordable Care Act marketplace, and $8 million from the Federal Employee Program.
 
“Our FIPR department protects our more than 6 million members and their healthcare dollars by stopping these threats,” says Jeff Bernhard, senior vice president of commercial markets for Highmark Inc. “They prevent schemes that not only raise costs, but also potentially put customers’ health at risk. For our self-insured customers, who have more exposure to higher-than-expected healthcare claims, these savings go right back to employers and drive down costs for their employees. And for all of our customers, preventing fraud, waste and abuse translates to lower costs and better care.”
 
FIPR utilizes an internal team that includes registered nurses, investigators, accountants, former law enforcement agents, clinical coders and programmers, complemented by an array of industry-leading vendors, to complete its objectives. As part of its work, the team performs audits to identify unusual claims, coding reviews and investigations that assess the appropriateness of provider payments.
 
Highmark’s FIPR department deploys numerous unique and industry leading initiatives to help ensure claims payment accuracy. Healthcare claims go through rigorous reviews, including automated AI algorithms as well as manual assessments. AI allows Highmark to detect and prevent suspicious activity more quickly, update insurance policies and guidelines, and stay attuned to the ever-changing schemes of bad actors.
 
“Fraud, waste and abuse in health care has become more prevalent, and more sophisticated, in recent years,” says Kurt Spear, vice president of FIPR for Highmark Inc. “FIPR combines innovative technology, the knowledge and experience of a multi-disciplinary team, and community partnerships to do right by our customers and stay ahead of bad actors in the health system.”
 
FIPR prevented approximately $7.5 million in fraud, waste and abuse related to COVID-19 in 2020, including preventive losses, overpayment recoveries and claim adjustments, and schemes related to vaccines, fake testing sites and personal protective equipment.
 
“We have posted national fraud alerts on COVID-19-related schemes, and have collaborated with provider partners including Allegheny Health Network to protect patients, customers and front-line workers,” says Melissa Anderson, executive vice president and chief audit and compliance officer for Highmark Health. “As the pandemic and related fraud schemes evolve, we’ll continue to target bad actors and guard the community’s well-being.”
 
About Highmark Inc.
One of America's leading health insurance organizations and an independent licensee of the Blue Cross Blue Shield Association, Highmark Inc. and its affiliated health plans work passionately to deliver high-quality, accessible, understandable, and affordable experiences, outcomes, and solutions to customers. As the fourth-largest overall Blue Cross Blue Shield-affiliated organization in membership, Highmark Inc. and its Blue-branded affiliates proudly cover the insurance needs of more than 6 million members in Pennsylvania, Delaware and West Virginia, along with Western and Northeastern New York. Its diversified businesses serve group customer and individual needs across the United States through dental insurance and other related businesses. For more information, visit www.highmark.com.

Top