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:

Efficient:

Highmark assesses claims automatically as they’re received.

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

Transparent:
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).

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

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

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

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

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Important Legal Information: Health benefits or health benefit administration may be provided by or through Highmark Blue Shield or one of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies serve Blue Cross Blue Shield members in the 29 counties of western Pennsylvania, 13 counties in northeast Pennsylvania, the state of West Virginia plus Washington County, Ohio, and the entire state of Delaware. Information on this website is issued by Highmark Blue Shield on behalf of its affiliated Blue companies.

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The information provided is intended to provide general information only and does not attempt to give you advice that relates to your specific circumstances. State laws and regulations governing health insurance and health plans may vary from state to state. Further, any information regarding any health plan will be subject to the terms of its particular health plan benefit agreement and some health plans may not be available in every region or state.