Case Study Highmark

Leading healthcare payer tightens grip on fraud with automated detection analysis

Within the first few months of implementing the tool, Highmark Special Investigations Unit (SIU) identified 83 new fraud cases. The average dollars and recoveries of just two cases more than paid for the software acquisition cost.

Highmark, the largest healthcare payer in Pennsylvania-and one of the largest commercial payers in the nation-wanted to beef up its system for fraud and abuse detection. By tightening its grip on fraud, the Pittsburgh-based Blue Cross/Blue Shield affiliate hoped to protect valuable healthcare dollars that might otherwise be lost or wasted, and to provide continuous access to quality, affordable healthcare insurance for all their customers.

Provider fraud and abuse takes many forms. Billing for services never rendered, double billing and outright fictitious claims are a few examples. A complex billing system combined with clever fraud schemes and the sheer volume of claims processed make fraud and abuse difficult to spot.

"We wanted a tool to detect potential fraudulent activity automatically, and that's what sold us on FICO. Highmark provides the data extracts, FICO handles the behind- the-scenes technology, and Highmark views the results. For us, the choice was a no-brainer."
—Denny Latsha,Project Manager, Highmark

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