Fraud Prevention

We Fight Health Care Fraud, Waste, and Abuse

Health insurance fraud is a quiet crime — no blaring sirens or masked gunmen. The only victims are the American taxpayers, and most of us don’t even realize we are being ripped off, say, by a provider billing for services that were never rendered.

Highmark has a long history on fighting healthcare fraud and the many forms it can take. Based on industry metrics, fraud ends up often costing anywhere between 3 – 10 percent annually of valuable healthcare dollars and can place our members’ health and safety at risk.

We partner with state and federal law enforcement agencies while also constantly innovating. This includes deploying AI (artificial intelligence) and other sophisticated analytical tools to help address fraud, waste and abuse that ultimately can impact Highmark’s customers. Our efforts result in Highmark consistently being recognized as an industry leader in our fraud and payment integrity programs.

Our Financial Investigations and Provider Review (FIPR) department prevents schemes that not only raise costs, but also potentially put customers’ health at risk. FIPR supports our company’s mission of providing affordable, quality health care by ensuring that provider reimbursements are appropriate and by investigating and resolving suspected incidents of insurance fraud, waste, or abuse externally or internally.

Types of Fraud Investigations

Here are some of the types of fraud actively pursued and examples of each.

• Provider Fraud: Billing for services not provided or billing for a more costly service than one performed, billing each stage of a procedure as it was separate, issuing kickbacks, billing for non-covered services or making a false diagnosis, setting up phony clinics to generate false claims.
• Subscriber Fraud: Allowing someone else to use your insurance card, using an insurance card that has been canceled, placing ineligible dependents on your plan, asking a provider to falsify a report to receive a non-covered procedure, asking a provider to waive a copayment, forging receipts to get reimbursement from the insurer.
• Pharmacy Fraud: Requesting, filing and dispensing illegitimate prescriptions.
• Group Fraud: Ghost employees or nonexistent employees, subscribers who are not employees, part-time employees, ineligible dependents.

FIPR combines innovative technology, the knowledge and experience of a multi-disciplinary team, and community partnerships to do right by our customers and stay ahead of bad actors in the health system.