Highmark makes an impact in the fight against health care fraud, waste and abuse in 2023

PITTSBURGH (January 24, 2024) — Highmark’s Financial Investigations and Provider Review (FIPR) department has made a cumulative financial impact of more than $1.6 billion in savings related to fraud, waste and abuse since 2017. The majority of these savings are classified as abuse in the form of up-coded medical claims, for example, and various billing errors. Regardless of the classification, these savings and the work that FIPR performs in collaboration with the entire Highmark enterprise and law enforcement help to lower health care costs and protect our customers. 

“Our FIPR department helps to protect our more than 7 million members and their health care dollars by stopping these threats,” says Kurt Spear, vice president of FIPR for Highmark. “While national schemes remain prevalent, we continue to deploy sophisticated artificial intelligence programs and partner with health systems, public health officials, law enforcement and other stakeholders to combat them. Fraud, waste and abuse significantly contributes to the rising cost of health care, and FIPR works to help lower those costs for our customers and members.”

FIPR utilizes an internal team 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 uses a number of tools to identify suspect claims including sophisticated data analytics. FIPR performs audits and investigations to assess these claims and the submitting providers for appropriateness.

In 2023, a resurgence of schemes targeting members on Affordable Care Act (ACA) plans affected many members nationwide. FIPR partnered across Highmark and with external stakeholders to identify and address these schemes early on to help limit the impact. FIPR also prevented millions in bogus claims from being paid for medically unnecessary durable medical equipment, another national health scheme. “Many of these schemes target our most vulnerable populations, including senior citizens,” says Spear. “Our goal is not only to address fraud, waste and abuse that impacts our members but also to help promote the safety and wellbeing of all individuals within our communities.”

“Fraud, waste and abuse in health care has become more sophisticated in recent years,” says Melissa Anderson, chief risk, audit and compliance officer for Highmark Health. “FIPR continues to combine 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.”