How tackling fraud keeps health care more affordable

Published February 20, 2020

Tens of billions of dollars are lost to health care fraud, waste and abuse every year. Those losses affect nearly everyone who pays for health care, leading to increased premiums and higher health care costs. What’s more, health care fraud is not a victimless crime: people who commit fraud may be hurting patients who don’t get the treatment they need. Highmark Blue Cross Blue Shield is winning awards for its efforts to stop fraud, helping keep costs lower for members and protecting patients.

It takes a team of expert investigators, sophisticated data analytics, and, often, savvy customer service representatives to spot and unravel fraudulent schemes. Highmark Blue Cross Blue Shield (Highmark BCBS) has all three. And the health plan is adding artificial intelligence, a powerful way to predict anomalies in claims or other data more quickly than traditional methods, to its toolbox. Anti-fraud efforts saved or recovered more than $260 million in 2019 alone.

Three recent success stories show the variety of cases – and the skill of investigators who solved the crimes.

Health care fraud investigations - three winning examples:

  • A rush of high-cost specialty medication claims raises suspicions
    Recently, Highmark BCBS’ fraud team (known as the Financial Investigations and Provider Review, or FIPR) spotted an unusual number and dollar amount of claims for specialty medications used to treat a rare disorder. Within just a few weeks, the health plan received $4.5 million in claims for these medications for a single employer group plan, from the same specialty pharmacy. Due to the rarity of the disorder and the number of those affected within a single employer group, the cluster of claims raised alarms. FIPR investigators identified the perpetrators and sued. The health plan and the perpetrators were able to reach a settlement under confidential terms. And for their work, FIPR won the National Health Care Anti-Fraud Association’s SIRIS Investigation of the Year Award that highlighted the successful national collaboration.
  • “Body brokering” puts addiction treatment money in the wrong pockets
    “Body brokering” schemes have been going on for years, but Highmark BCBS investigators and cutting edge analytics have sharpened the health plan’s ability to spot and shut them down. Body brokers find vulnerable people who need substance use disorder treatment but who don’t have insurance. They sign them up for an Affordable Care Act (ACA) policy, under false pretenses and with fraudulent enrollment information, send them to a treatment center that is sometimes in on the scheme and receive a kick-back. The center then bills the insurance company for care that may or may not be high quality. Investigators spotted tell-tale signs of these schemes in two recent scenarios. In one, Highmark BCBS received high numbers of ACA applications from a single treatment center. In another, investigators noticed a spike in new applications from a single small town in Pennsylvania. Highmark BCBS’ sophisticated analytics are helping investigators stop these kinds of schemes earlier and prevent even greater losses. FIPR director Latrisha Oswald and her team always work to help affected members receive the treatment they need.
  • Telemarketers conspire with pharmacies to profit from unwanted prescriptions
    Oswald says that some members began calling Highmark BCBS to say they were receiving deliveries of topical pain creams they’d never ordered, prescribed by doctors they didn’t know. The health plan then started seeing claims for all of this unwanted medication. Quickly connecting the dots in the data, Oswald’s team unmasked a telemarketing company, pharmacies and doctors behind the operation. To head off similar schemes in the future, Highmark BCBS no longer pays claims for prescriptions from doctors that have no established relationship with a patient. The investigation saved over $20 million with additional pharmacies being shut down that continue to pop up in the lucrative scheme.

How tackling fraud keeps health care more affordable:

“…Health care fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage. For employers—private and government alike—health care fraud increases the cost of providing insurance benefits to employees which, in turn, increases the overall cost of doing business.” – National Health Care Anti-Fraud Association, a public-private partnership

Health care fraud: what to do if you suspect a problem

If you suspect health care fraud, consult these resources from Highmark Blue Cross Blue Shield and these resources from the Blue Cross Blue Shield Association. Or, you can report fraud through the Centers for Medicare and Medicaid.

Highmark Blue Cross Blue Shield is an independent licensee of the Blue Cross Blue Shield Association, an association of independent, locally operated Blue Cross and Blue Shield companies.