Highmark Inc.’s anti-fraud efforts continue to be highly effective in combating fraud, waste and abuse (FWA). Highmark, based in Pittsburgh, is one of the two largest health insurers in Delaware.
During the past five years the company’s fraud team has helped to detect or prevent abuses such as fraudulent claims, saving hundreds of millions of dollars for its customers and the company. In 2016 alone, the team made a financial impact of upwards of $149 million.
The team continues to use sophisticated data analytic tools to look for 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.”
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 above shows the financial impact that Highmark’s FIPR department has made from 2013 – 2016.
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 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.”
