Highmark Makes $245 Million Impact on Healthcare Fraud, Waste and Abuse | News, Sports, Jobs

PITTSBURGH – Highmark’s Financial Investigations and Vendor Review department generated more than $245 million in savings from fraud, waste and abuse in 2021 and had a cumulative financial impact of nearly $1 billion in these activities since 2017.

“FIPR protects the premiums and well-being of Highmark customers, ensuring healthcare spending supports high-value care for our more than 6 million members by eliminating bad actors, inefficiencies and errors” , Kurt Spear, FIPR vice president for Highmark Inc., said. “IFPR accomplishes this work by deploying sophisticated artificial intelligence programs and partnering with health systems, public health officials, law enforcement and other health actors.”

Highmark prevented significant fraud, waste and abuse across various business segments and in the communities it serves in 2021. This includes approximately $152 million in savings related to employer 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 market, and $9 million from federal employee program dollars.

FIPR savings in 2021 included approximately $184 million of activities related to billing/coding errors, fraud, waste and abuse in Pennsylvania, $25 million in West Virginia and $23 million in Delaware .

“FIPR deploys industry-leading initiatives and technology, a multi-disciplinary team and strong community partnerships to ensure claims payment accuracy and do the right thing for our customers,” says Melissa Anderson, executive vice president and chief risk and compliance officer at Highmark Health. “Healthcare claims undergo rigorous reviews, including automated AI algorithms as well as manual assessments. AI enables Highmark to detect and prevent suspicious activity faster, update insurance policies and guidelines, and to stay ahead of new schemes and malicious actors. FIPR’s work translates into lower costs, better care and peace of mind for all of our clients.

FIPR has an in-house team of more than 80 people that includes registered nurses, investigators, accountants, former law enforcement officers, clinical coders and programmers, complemented by an array of industry-leading vendors. industry to achieve its goals. As part of its work, the team conducts audits to identify unusual claims, coding reviews and investigations that assess the adequacy of vendor payments.

Since 2014, law enforcement investigations of fraud, waste and abuse detected by the FIPR have resulted in 94 arrests, indictments and convictions in 29 states, affecting 70 providers and resulting in the closure of 157 pharmacies. Convictions for cases involving the FIPR since 2018 have resulted in 125 months probation, 244 months in prison and $603,000 restitution.

Highmark is one of America’s leading health insurance organizations and an independent licensee of the Blue Cross Blue Shield Association. Highmark represents over 6 million members in Pennsylvania, Delaware, West Virginia and New York.