Pittsburgh-based Highmark uncovered $260 million in savings related to fraud, waste and abuse in 2019, the health insurer said Feb. 3.
Highmark's Financial Investigations and Provider Review department has saved more than $850 million in the past five years by identifying, preventing and stopping possible fraudulent activities. The savings include prevented losses, recoveries and policy savings.
FIPR uses an internal team of registered nurses, investigators, accountants, former law enforcement agents, clinical coders and programmers to identify fraudulent billing. In 2020, Highmark's FIPR department launched artificial intelligence to review claims.
"Although just recently implemented, we're already seeing positive results from our AI software," Kurt Spear, vice president of financial investigations and provider review for Highmark, said in a prepared statement. "The goal of AI is to adapt quickly to changing behavior and to help predict aberrancies earlier than traditional tools that often rely on established rules to catch suspicious behavior. We know it is much easier to stop these bad actors before the money goes out the door [than] pay and have to chase them."
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