Artificial Intelligence Saved Over $260M in Fraud, Waste in 2019

Highmark Inc.’s Financial Investigations and Provider Review (FIPR) department has leveraged artificial intelligence to generate over $260 million in savings associated with fraud, waste, and abuse in 2019, and has saved over $850 million in the last five years.

The insurance organization is using advanced AI tools to detect indicators of fraudulent activity much faster than before. Highmark is also employing strategies to limit financial exposure of their customers. In 2020, FIPR is utilizing AI to further enhance the company’s ability to identify, prevent, and stop fraudulent activities.

“We know the overwhelming majority of providers do the right thing. But we also know year after year millions of health care dollars are lost to fraud, waste and abuse,” said Melissa Anderson, executive vice president and chief audit and compliance officer, Highmark Health. “By using technology and working with other Blue Plans and law enforcement, we have continually evolved our processes and are proud to be among the best nationally.”

FIPR uses an internal team made up of registered nurses, investigators, accountants, former law enforcement agents, clinical coders, and programmers. The team performs audits to detect unusual claims, coding reviews, and investigations that evaluate the appropriateness of provider payments.

“Highmark’s Payment Integrity program deploys twenty-eight unique initiatives to help ensure claims payment accuracy. Fifteen of these initiatives are embedded within our FIPR department and aim directly at addressing instances of fraud, waste and abuse. Healthcare claims go through rigorous reviews, including automated AI algorithms as well as manual assessments,” said Kurt Spear, vice president of financial investigations and provider review for Highmark Inc.

“Although just recently implemented, we’re already seeing positive results from our AI software. 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 then pay and have to chase them.”

Recently, Change Healthcare conducted a review of Highmark Inc.’s Payment Integrity programs, including FIPR. The review showed that Highmark’s program outperforms the industry standard and saves approximately ten percent of medical claims for group customers, and nearly 33 percent more savings than other national payers.

“We have known for some time that our programs have substantial return on investment and were top notch. This external review proves that we are among the best in the nation, and that means real savings for our Highmark regional and national customers,” said Jeff Bernhard, senior vice president of national and commercial markets, Highmark Inc.

“This is also a benefit to our Sales teams when out competing to win business. They can share this information with our prospective customers and truly benchmark Highmark, and show it superiority around fraud and waste controls, compared to other insurance carriers.”

AI has emerged as a viable, innovative way to reduce fraud and waste in the healthcare system. In a recent Optum survey of health industry leaders, 43 percent said they believe that AI will help detect fraud, waste, or abuse in reimbursement.

Health IT experts have increasingly recognized that AI can help identify which patients need testing for certain conditions, decreasing healthcare spending.

“Low risk patients are getting over-tested, and high risk patients aren’t getting tested enough,” Ziad Obermeyer, MD, Assistant Professor of Emergency Medicine at Brigham and Women’s Hospital, said at the 2018 World Medical Innovation Forum.

“The fact that nobody is getting this balance right is the key to seeing how an algorithm can do so much better. If an algorithm was making the decisions, we could cut tests by about 40 percent and still find about as many patients who will go on to have cardiovascular interventions.”

CMS has also adopted AI and other advanced technology in an effort to reduce Medicare fraud, waste, and abuse. In October 2019, the agency unveiled a new five-pillar approach to detecting fraudulent activity based on prevention and technology.

“As our programs become more complex, program integrity risks become increasingly difficult to recognize,” Seema Verma, CMS Administrator wrote in a blogpost.

As the healthcare industry seeks new and advanced ways to improve care quality and streamline processes, AI tools will continue to permeate payer and provider landscapes.