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Highmark Inc.'s anti-fraud, waste and abuse measures save members millions

Highmark Inc.

PITTSBURGH (June 3, 2015) — Highmark Inc., one of the nation's largest health insurers, recently announced that its measures to combat fraud, waste and abuse had a financial impact of more than $100 million in 2014. The company's Financial Investigations and Provider Review (FIPR) area, which leads the effort, expects this figure to exceed $115 million in 2015.

"Highmark FIPR supports the company's mission to provide affordable, quality health care by helping to ensure that provider reimbursements are appropriate — protecting Highmark's and our customers' assets. We do this by preventing, investigating and resolving incidents of health care fraud, waste and abuse," said Highmark Vice President FIPR Kurt Spear. "Our goal is to help our members receive quality and affordable health care in a safe environment."

The National Health Care Anti-Fraud Association estimates that 3-10 percent of dollars spent on health care is lost to fraud. With annual health care expenditures in the U.S. expected to exceed $3 trillion, the loss to fraud amounts to $90-300 billion.

Highmark FIPR's role is to investigate and resolve alleged incidences of fraud, waste and abuse and then pursue financial recovery as necessary. FIPR successfully closed out more than 2,400 cases in 2014. This success is accomplished through audit programs that use data analysis techniques to identify unusual claims, coding reviews and investigations that assess the appropriateness of provider payments. FIPR utilizes an internal team made up of registered nurses, investigators, accountants, former law enforcement agents and programmers, complemented by an array of industry leading vendors, to complete its objectives.

"Fraud is a major concern for the entire health care industry," said Spear. "Successful fraud prevention relies on referrals from members, employees and providers; strong relationships with law enforcement personnel who receive information to support criminal health care fraud investigations; and continual analysis of health care claim patterns and investigation of red flags."

Highmark encourages individuals to report suspected cases health care fraud, waste or abuse confidentially by calling 1-800-438-2478.

About Highmark Inc.

Highmark Inc. is among the ten largest health insurers in the United States and is the fourth-largest Blue Cross and Blue Shield-affiliated company. Highmark and its diversified businesses and affiliates operate health insurance plans in Pennsylvania, Delaware and West Virginia that serve 5.3 million members. Its diversified health businesses serve group customer and individual health needs across the United States through dental insurance, vision care and other related health businesses. Highmark 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.
For more information, contact:
David Misner
Highmark Inc.
717-302-3638
david.misner@highmarkhealth.org