Health insurer Highmark Health said it saved over $245 million last year by rooting out fraud, waste and abuse, a disclosure that quickly riled up doctors.
The Blue Cross Blue Shield Association requires that its 35 member companies have such programs to detect improper claims, but it doesn't release aggregate results publicly. Pittsburgh, Pennsylvania-based Highmark said it wants to be open about the savings its program is generating, which total almost $1 billion since 2017.
"We think it's important to help our consumers really understand what we're doing to help them lower the cost of healthcare," said Kurt Spear, vice president of Highmark's Financial Investigations and Provider Review department.
On its face, fraud detection might not sound controversial. But Highmark's report highlights the tension between insurers undertaking what they deem routine claims inspections and providers feeling those efforts are overly aggressive and chipping away at their revenue.
Highmark's report drew a strongly worded response from the powerful American Medical Association. AMA President Dr. Gerald Harmon said in a statement that fraud and abuse efforts should be guided by transparent rules that distinguish intentional acts to defraud from occasional or accidental billing or coding errors.
"Health insurers should not be allowed to subject practices to burdensome administrative processes or intimidate physicians who are merely victims of confusing, complex and nontransparent health insurer payment rules and requirements," Harmon said.
Most of what gets picked up through programs like Highmark's are routine billing errors: a former member switched jobs or a bill should have gone to an auto insurer, said Nathan Ray, a partner in West Monroe's healthcare and life sciences practice. Highmark's numbers would be more helpful if they showed what proportion were accidental billing errors versus intentional fraud, he said.
The AMA posts content to help doctors understand how to complete claims correctly, Ray noted.
"So they themselves understand there is an appropriate decorum for how you process a claim and if those things aren't met, a claim shouldn't be paid or should be reviewed at least," he said. "That, by and large, is where these types of dollar figures are coming from."