Claims Integrity

Approximately 7% of health care spending is lost to fraud every year.1 Highmark is committed to helping your organization control costs, and that commitment includes working to reduce and eliminate health care fraud, waste, and abuse. We use a meticulous process that protects your money from start to finish.

Health Care Fraud Prevention and Claims Integrity: How Highmark Helps

At Highmark, we protect your dollars from start to finish. Whether we’re preventing health care providers from subjecting patients to unnecessary medical procedures or identifying overpayments, our oversight starts as soon as claims are submitted and doesn’t end until after they’re paid.

This commitment to payment integrity saved an estimated $270 million in 2017.2

To ensure claims integrity, we are:



Highmark assesses claims automatically as they’re received.


We meticulously cross-check payment or denial decisions based on benefits, and we perform post-payment audits


Highmark uses a payment integrity policy library to enforce industry-standard payment policies for third-party claims. And we analyze claims to identify FWA (federal-wide assurance).


As we review post-payment claim queries, we make adjustments, ensure benefits were coordinated properly, and conduct a quality review to verify correct processing.


We initiate provider education, pharmacy lock-in programs, and medical policy work groups.

1 Harvard Business Review: How the U.S. Can Reduce Waste in Health Care Spending by $1 Trillion, 2015.

2 Based on independent assessment by industry experts in 2016/2017.

Stay Connected

Help your employees take advantage of all their health plan has to offer, including our member portal, online tools, and member discounts.