Highmark’s efforts against fraud, waste and abuse lead to record savings in 2025

PITTSBURGH (February 12, 2026) — In 2025, Highmark’s Financial Investigations and Provider Review (FIPR) department significantly advanced its fight against health care fraud, waste and abuse. By playing a critical role in major national investigations and expanding robust prevention programs, Highmark reinforced its commitment to protecting members, safeguarding health care resources, and helping to lower the cost of care.

FIPR was instrumental in “Operation Gold Rush,” a landmark U.S. Justice Department investigation unveiled on June 30, 2025. This nationwide operation exposed a transnational criminal organization responsible for the largest financial loss ever charged in a departmental health care fraud case, totaling $10.6 billion in fraudulent claims.

Highmark proactively provided essential false claims data to law enforcement, contributing to the investigation that led to charges against 19 defendants. The criminal organization had allegedly created a vast network of fake companies, using stolen identities of over one million Americans and illicit medical information to bill Medicare for urinary catheters and other durable medical equipment.

"Highmark’s proactive mitigation strategies, including the development and implementation of a pre-payment claims solution, was vital in blocking payments to phantom providers identified in this scheme," says Kurt Spear, vice president of FIPR for Highmark. "Our swift action demonstrates our ability to identify and prevent fraud on a large scale." Law enforcement efforts associated with Operation Gold Rush have, to date, resulted in the seizure of approximately $27.7 million in illicit funds.

FIPR was also at the forefront of tackling a re-emerging national false enrollment scheme that targets individuals with substance use disorders (SUD) seeking treatment. This complex scheme involves third parties enrolling ineligible individuals in State/Federal Affordable Care Act (ACA) Plans, often using fully subsidized policies and recruiting Medicaid enrollees for out-of-state treatment.

Highmark coordinated with other Blue plans, Centers for Medicare & Medicaid Services (CMS), State Exchanges, and law enforcement to raise awareness and rescind improper policies. They also educated affected providers and members, strengthened claim review processes and referred cases to law enforcement. FIPR also adjusted pricing strategies, including how Blue Card claims are processed, to remove financial incentives for bad actors, while ensuring members still have access to quality care.

Highmark continued to strengthen its established programs, further protecting members and communities:

• Elder Financial Fraud Awareness: Highmark’s FIPR team maintained its impactful partnership with the Federal Bureau of Investigation’s (FBI) Pittsburgh Field Office. Through community outreach and an educational video featuring real victims, these events educated seniors on prevalent schemes like romance, technology support, grandparent, and lottery scams, empowering them to protect their financial well-being.
• Designated Pharmacy Program (DPP): Launched in 2014, the DPP continues to improve care coordination, minimize fraud, waste, and abuse, and reduce unnecessary prescriptions. In 2025, the program achieved a 14% reduction in suspect pill counts and a 20.7% reduction in suspect script utilization. It also identified 236 members who are now receiving rehabilitation treatment, alongside a 31% reduction in suspect ER utilization and a 28.86% reduction in urgent care utilization.
• Prescription Monitoring Program (PDMP): Established in 2019, this collaborative program with the Department of Health, law enforcement, and Highmark member outreach teams ensures appropriate medication access and support for substance use disorder treatment. Since its inception, the PDMP has referred 732 members to Behavioral Health Services (BHS), achieved a reduction of 464,028 suspect units of controlled substances, and contributed to 210 total national DEA surrenders.

"Protecting our members from financial harm and ensuring the responsible use of healthcare resources is central to Highmark’s mission," says Tim Law, DO, chief medical officer for Highmark. "By investing in advanced analytics, fostering strong partnerships, and empowering individuals with knowledge, we are strengthening the integrity of the healthcare system and fostering a more secure environment for all."