Highmark Inc.'s Anti-Fraud Department using Artificial Intelligence to reduce fraud, waste and abuse impact

PITTSBURGH (February 03, 2020) — Highmark Inc.'s Financial Investigations and Provider Review (FIPR) department made a financial impact of over $260 million in savings related to fraud, waste and abuse in 2019 and has saved more than $850 million over the past five years. In 2020, FIPR is successfully using artificial intelligence (AI) to enhance the company's ability to identify, prevent and stop potentially fraudulent activities earlier than ever.

"We know the overwhelming majority of providers do the right thing. But we also know year after year millions of health care dollars are lost to fraud, waste and abuse," said Melissa Anderson, executive vice president and chief audit and compliance officer, Highmark Health. "By using technology and working with other Blue Plans and law enforcement, we have continually evolved our processes and are proud to be among the best nationally."

Kurt Spear, vice president of financial investigations and provider review for Highmark Inc., said AI is a game-changer for everyone.

"Highmark's Payment Integrity program deploys twenty eight unique initiatives to help ensure claims payment accuracy. Fifteen of these initiatives are embedded within our FIPR department and aim directly at addressing instances of fraud, waste and abuse. Healthcare claims go through rigorous reviews, including automated AI algorithms as well as manual assessments," he said. "Although just recently implemented, we're already seeing positive results from our AI software. The goal of AI is to adapt quickly to changing behavior and to help predict aberrancies earlier than traditional tools that often rely on established rules to catch suspicious behavior. We know it is much easier to stop these bad actors before the money goes out the door then pay and have to chase them."

Spear said these very sophisticated tools are looking at algorithms and patterns to detect indicators of fraudulent activity much sooner than in the past. He noted that as bad actors use social media and other tools and evolve their schemes, Highmark also leverages best practices to limit financial exposure for our customers. As further noted below, the results of Highmark's anti-fraud department continue to be recognized as industry leading.

Here is a chart of the savings from 2015 – 2019.

National Independent External Review

Breaking down 2019, Spear said the $260 million in financial impact includes prevented losses, recovered money and policy savings.

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 performs audits to identify unusual claims, coding reviews and investigations that assess the appropriateness of provider payments.

National Awards

In late 2019, Highmark's Financial Investigations and Provider Review (FIPR) department was honored by the National Health Care Anti-Fraud Association (NHCAA) with the Special Investigation Resource and Intelligence System (SIRIS) Investigation of the Year award. This is considered among the top awards in the nation. The investigation involved a specialty pharmacy supplying excessive amounts of hemophilia factor medications to patients. In order to drive up their reimbursement, the pharmacy would create shell employer groups that would enroll as an ACA small group. Ultimately, the scheme was shut down.

NHCAA also recognized Highmark with a second award for Excellence in Public Awareness for Highmark's Opioid Epidemic Education Program.

"The goal of our program is to educate students, facilitators and parents about the opioid epidemic. The presentation to students, faculty and parents addresses understanding opioids, fentanyl, heroin and deadly drug combinations, being empowered to say 'no', the stigma of addiction and key takeaways for real-life situations. Highmark has reached more than 8,500 students and plans to continue the program in 2020," Spear said.