Law and Order at Highmark

A Pennsylvania-based Blue Cross Blue Shield affiliate deserves high marks for taking an $11.5 million-plus bite out of healthcare fraud that costs the U.S. as much as $170 billion annually. The company, Highmark, also earns an “A” in cross-functional collaboration, antifraud technology, and relationship management with providers and other stakeholders.

Three years ago, Highmark, which provides health insurance to more than 25 million individuals, developed a new antifraud analytics application it dubbed the “Financial Investigation Reporting System for Tomorrow” (FIRST). After one year of use, FIRST, along with the sleuthing savvy of the company's special investigations unit (SIU) personnel and the analytics mastery of Highmark's healthcare informatics group, helped the company to generate $11.5 million in claims recovery and cost avoidance.

Since then, the annual cost savings — produced by a combination of claims recovery and cost avoidance as well as process and systems improvements sparked by the antifraud investigative work — generated each year have been “more significant than the prior year,” SIU Director Tom Brennan reports. “I still need to demonstrate that monthly ROI to my boss, and we're still generating plenty of ROI.”