PITTSBURGH – Highmark Inc.’s Financial Investigations and Provider Review (FIPR) department is working with the U.S. Attorney’s Office for the Western District of Pennsylvania in its ongoing fight against opioids. This work with the U.S. Attorney’s Opioid Fraud Task Force marks the latest milestone in the department’s continued mission to combat health care fraud. In 2017 alone, FIPR realized a total savings of more than $183 million.
“We know we’re making a significant impact and helping to protect our members,” said Kurt Spear, vice president of Financial Investigation and Provider Review, Highmark Inc. “Our team’s recent collaboration with the Western Pennsylvania Opioid Fraud and Abuse Detection Unit is an exciting advancement in our mission to detect and investigate fraudulent claims. Our referrals have contributed to several health care fraud investigations and prosecutions by the U.S. Attorney’s Office.”
In addition to its work in the fight against opioids, FIPR uses highly sophisticated data analytic tools, audit programs, community outreach and tip hotlines to look for and prevent fraud, waste and abuse (FWA) in various forms. Since 2012, the department has saved a total of nearly $700 million.
| Year | Actual Savings |
|---|---|
|
2012 |
$58,700,000 |
|
2013 |
$82,700,000 |
|
2014 |
$104,700,000 |
|
2015 |
$119,500,000 |
|
2016 |
$148,700,000 |
|
2017 |
$183,800,000 |
This chart shows the financial impact that Highmark's FIPR department has made from 2012-2017. The graph represents dollars recovered from medical claim reimbursements made to providers as a result of FWA, savings in the form of policy changes that have helped close risk areas for FWA, as well as prevented losses such as medical claims that have been identified as being improper FWA and have been stopped (not paid). FIPR uses the same categories to define FWA related financial impact (i.e., recoveries, savings, prevented losses) as many other payers and CMS.
FIPR utilizes an internal team that includes registered nurses, investigators, accountants, former law enforcement agents and programmers, complemented by an array of industry leading vendors, to complete its objectives. As part of its work, the team reviews audits to identify unusual claims, coding reviews and investigations that assess the appropriateness of provider payments.
Spear added that to amplify the team’s impact, he spearheads purposeful relationships with community partners and government officials, such as the U.S. Attorney’s Office’s Opioid Fraud Task Force.
FIPR also made strides last year with the introduction of a local opioid educational initiative – known for being the first of its kind driven by a payer’s fraud department. FIPR worked with Allegheny Health Network and the Drug Enforcement Agency to educate junior and senior high school students on the severity of the epidemic in our region and across the country.
Highmark formally declared its war on opioids in February 2018, making a commitment to enact programs and initiatives as well as funding to help members and their families as they battle opioid abuse and addiction.
About Highmark Inc.
Highmark Inc. and its health insurance subsidiaries and affiliates collectively are among the ten largest health insurers in the United States and comprise the fourth-largest Blue Cross and Blue Shield-affiliated organization. Highmark Inc. and affiliates operate health insurance plans in Pennsylvania, Delaware and West Virginia that serve 5 million members and hundreds of thousands of additional members through the BlueCard® program. Its diversified businesses serve group customer and individual needs across the United States through dental insurance, vision care and other related businesses. Highmark Inc. is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. For more information, visit www.highmark.com.