Health insurance fraud is a quiet crime — no blaring sirens or masked gunmen. The only victims are the American taxpayers, and most of us don’t even realize we are being ripped off, say, by a provider billing for services that were never rendered.
Highmark has a long history on fighting healthcare fraud and the many forms it can take. Based on industry metrics, fraud ends up often costing anywhere between 3 – 10 percent annually of valuable healthcare dollars and can place our members’ health and safety at risk.
We partner with state and federal law enforcement agencies while also constantly innovating. This includes deploying AI (artificial intelligence) and other sophisticated analytical tools to help address fraud, waste and abuse that ultimately can impact Highmark’s customers. Our efforts result in Highmark consistently being recognized as an industry leader in our fraud and payment integrity programs.
Our Financial Investigations and Provider Review (FIPR) department prevents schemes that not only raise costs, but also potentially put customers’ health at risk. FIPR supports our company’s mission of providing affordable, quality health care by ensuring that provider reimbursements are appropriate and by investigating and resolving suspected incidents of insurance fraud, waste, or abuse externally or internally.
Types of Fraud Investigations
Here are some of the types of fraud actively pursued and examples of each.
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.
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All references to “Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health benefit administration and/or to one or more of its affiliated Blue companies. This website is operated by Highmark, Inc. and is not the Health Insurance Marketplace website. It also does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.
Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal. ®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Wholecare or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company, Highmark Wholecare or Highmark Senior Health Company. PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield or Highmark BCBSD Health Options Inc. d/b/a Highmark Health Options. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company, or Highmark Senior Solutions Company or Highmark Health Options West Virginia Inc. d/b/a Highmark Health Options. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.