Highmark generated more than $245 million in savings related to fraud, waste and abuse last year through its Financial Investigations and Provider Review department, the insurer announced this week.
The department, Highmark said, has had a cumulative financial impact of about $1 billion on such activity since 2017.
Of the 2021 savings, $152 million in savings was related to employer-sponsored health insurance, as well as $49 million from the Blue Card program, which allows Highmark members to access national Blue Cross Blue Shield networks. In addition, $19 million in savings were from Medicare Advantage, $16 million in the Affordable Care Act marketplaces and $9 million from the Federal Employee Program.
“FIPR protects Highmark customers’ premium dollars and well-being, ensuring that health spending supports high-value care for our more than 6 million members by rooting out bad actors, inefficiencies and errors,” says Kurt Spear, vice president of FIPR for Highmark Inc., in a statement. "FIPR accomplishes that work by deploying sophisticated artificial intelligence programs and partnering with health systems, public health officials, law enforcement and other health stakeholders.”
RELATED: DOJ recovers over $5B in healthcare fraud settlements, judgments in 2021
Most of the savings, about $184 million, were related to billing or coding errors, fraud, waste and abuse in Pennsylvania, Highmark said. FIPR found $25 million in savings in West Virginia, and $13 million in Delaware, according to the announcement.
The department includes a team of more than 80 people, Highmark said, such as nurses, investigators, accountants, former law enforcement agents and programmers. It conducts audits to identify unusual claims, coding reviews and investigations to review provider payments.
“FIPR deploys industry-leading initiatives and technology, a multi-disciplinary team and strong community partnerships to ensure claims payment accuracy and do right by our customers,” says Melissa Anderson, executive vice president and chief risk and compliance officer for Highmark Health, in a statement.
“Healthcare claims go through rigorous reviews, including automated AI algorithms as well as manual assessments. AI allows Highmark to detect and prevent suspicious activity more quickly, update insurance policies and guidelines, and stay ahead of new schemes and bad actors," Anderson said. "FIPR’s work translates to lower costs, better care and peace of mind for all of our customers.”