Highmark Inc.’s anti-fraud programs continue to see results  

Highmark’s Financial Investigations and Provider Review (FIPR) department in particular has made a significant impact from 2013 – 2016, using highly sophisticated data analytic tools to look for fraud, waste and abuse (FWA) as it can take many different forms.

“We can see how providers compare to their peers and investigate based on aberrancies.  For example, if someone is billing for three times more office visits than their peers or billing for services that exceed 24 hours on a given day,  then we will launch an investigation into the provider’s practices ,” said Kurt Spear, vice president, Financial Investigation and Provider Review, Highmark Inc. “We also actively look for member related fraud -which also occurs.  In addition to using sophisticated data analytics and a host of other tools, the team also uses tips received into our fraud hotline, which are often very effective.”

Spear added that there are limited health care dollars available, so when fraud occurs, critical funds that should be used for actual care are wasted.

The National Health Care Anti-Fraud Association estimates that 3-10 percent of dollars spent on health care is lost to fraud. With annual health care expenditures in the U.S. expected to exceed $3 trillion, the loss to fraud amounts to $90-300 billion.

Year – Actual Savings
2012 – $58,700,000
2013 – $82,700,000
2014 – $104,700,000
2015 – $119,500,000
2016 – $148,700,000

This chart shows the financial impact that Highmark’s FIPR department has made from  2013 – 2016. The graph represents dollars recovered from medical claim reimbursements made to providers as a result of FWA, savings in the form of policy changes that have helped close risk areas for FWA, as well as prevented losses such as medical claims that have been identified as being improper FWA and have been stopped (not paid). FIPR uses the same categories to define FWA related financial impact (i.e., recoveries, savings, prevented losses) as many other payers and CMS.

Spear added that this success is accomplished through audit programs that use data analysis techniques to identify unusual claims, coding reviews and investigations that assess the appropriateness of provider payments. FIPR utilizes an internal team that includes registered nurses, investigators, accountants, former law enforcement agents and programmers, complemented by an array of industry leading vendors, to complete its objectives.

“We know we are making a significant impact and helping to protect our members,” said Spear. “Anyone can help prevent fraud by reporting suspected cases. If you know of a health care provider that is submitting inappropriate claims or someone that is abusing their health insurance benefits, report it.”

Highmark encourages individuals to report suspected cases health care fraud, waste or abuse confidentially by calling 1-800-438-2478.