Highmark makes significant strides in community education and health care fraud prevention in 2024

PITTSBURGH (February 5, 2025) – Highmark’s Financial Investigations and Provider Review (FIPR) department significantly expanded its community education efforts in 2024, empowering residents to protect themselves against health care fraud, waste and abuse. This commitment builds upon FIPR’s longstanding success in combatting fraud, resulting in over $2 billion in savings since 2017. Most of these savings are classified as errors and abuse in the form of various billing issues including up-coded medical claims, when billing codes are submitted for more expensive services than the ones a patient receives. 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.

In a key initiative during the first half of 2024, Highmark’s FIPR team partnered with the Federal Bureau of Investigation’s (FBI) Pittsburgh Field Office to launch a comprehensive elder fraud awareness campaign. According to the latest FBI Elder Fraud Report, financial fraud for Americans over age 60 accounts for $3.1 billion total losses and over 88,262 complaints filed. Addressing these alarming statistics, this collaboration focused on educating seniors about prevalent schemes, including romance, technology support, grandparent and lottery scams.

The program leveraged a multi-faceted approach, including engaging multimedia resources, accessible and direct engagement through in-person education at Highmark Direct Stores, and impactful community outreach including a joint press conference with the FBI and an educational video featuring real victims of fraud.

The impactful program reached over 650,000 seniors and earned Highmark’s Elder Fraud Awareness initiative the prestigious 2024 Excellence in Public Awareness Award from the National Health Care Anti-Fraud Association (NHCAA), recognizing the exceptional collaboration between Highmark Inc., Highmark Health, the FBI Pittsburgh Field Office and dedicated employees across all participating organizations.

“This recognition underscores the importance of collaborative partnerships and the vital need to protect seniors in our community from the devastating impact of elder fraud,” says Kurt Spear, vice president of FIPR for Highmark. “Our joint efforts with the FBI allowed us to reach hundreds of thousands of seniors with crucial information, empowering them to safeguard their wellbeing and financial security.”

FIPR also advanced its existing programs, demonstrating continued success in protecting members:

• Designated Pharmacy Program (DPP): Launched in 2014, the DPP continues to improve care coordination, minimize fraud, waste and abuse, and reduce unnecessary prescriptions. As of December 31, 2024, the DPP achieved a 30.6 percent reduction in urgent care utilization and emergency room visits, a 21.1 percent reduction in controlled substance prescriptions and provided addiction treatment to 233 members. The program reduced the dispensed quantity of focus medication by 757,584 units, including a 15 percent decrease in tablets and capsules.
• Prescription Monitoring Program (PDMP): Established in 2019, this collaborative program with the Department of Health, law enforcement and Highmark member outreach teams ensures members receive appropriate medication access and necessary support for substance use disorder treatment. Since its inception, the PDMP has examined 181 Drug Enforcement Administration (DEA) license surrenders across 26 states and referred 682 members to behavioral health services. This initiative directly addresses the critical need for continuity of care when providers lose their DEA prescribing license. 

“Protecting our members from financial harm is only part of Highmark’s mission,” says Tim Law, DO, chief medical officer for Highmark. “By empowering individuals with knowledge and resources, we’re strengthening the overall integrity of the healthcare system and fostering a more secure environment for everyone.”