Highmark makes $245M impact in fight against healthcare fraud
Highmark’s Financial Investigations and Provider Review department generated more than $245 million in savings related to fraud, waste and abuse in 2021, and has made a cumulative financial impact of nearly $1 billion in such activity since 2017.
“FIPR protects Highmark customers’ premium dollars and well-being, ensuring that health spending supports high-value care for our more than 6 million members by rooting out bad actors, inefficiencies and errors,” said Kurt Spear, vice president of Highmark Inc.’s Financial Investigations and Provider Review department. “FIPR accomplishes that work by deploying sophisticated artificial intelligence programs, and partnering with health systems, public health officials, law enforcement and other health stakeholders.”
Highmark prevented significant fraud, waste and abuse across various business segments and across the communities that it serves in 2021. That includes approximately $152 million in savings related to employer-based health insurance; $49 million from the Blue Card program, which provides Highmark customers with access to national Blue Cross Blue Shield networks; $19 million from Medicare Advantage; $16 million from the Affordable Care Act marketplace; and $9 million from the Federal Employee Program.
The department’s 2021 savings included approximately $23 million in activity related to billing/coding errors, fraud, waste and abuse in Delaware, $184 million in in Pennsylvania and $25 million in West Virginia.
“FIPR deploys industry-leading initiatives and technology, a multidisciplinary team and strong community partnerships to ensure claims payment accuracy and do right by our customers,” said Melissa Anderson, executive vice president and chief risk and compliance officer for Highmark Health. “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 ahead of new schemes and bad actors. FIPR’s work translates to lower costs, better care and peace of mind for all of our customers.”
The department features an internal team of more than 80 people 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.
Since 2014, law enforcement investigations involving fraud, waste and abuse detected by the review department have resulted in 94 arrests, indictments and convictions across 29 states, impacting 70 providers and resulting in 157 pharmacy terminations. Sentencing for FIPR-involved cases since 2018 have resulted in 125 months of probation, 244 months of prison time and restitution of $603,000.
