Highmark Scores High Marks Against Health Fraud

Pittsburgh-based Highmark Inc., a part of the Blue Cross/Blue Shield organization has wrapped up an enviable record in combating health care fraud, with 33 convictions and 33 indictments in 2001 and first quarter 2002 as a result of its investigative efforts.

The number is the “highest amount ever,” said the company.”During the same period, Highmark uncovered $3.4 million in health insurance fraud. Of the $3.4 million, nearly $600,000 represented claims submitted, but not paid as a result of the efforts of Highmark’s Special Investigations Unit (SIU), an 18-member team dedicated to detection and investigation of fraud and abuse across Pennsylvania,” it continued..

Thomas Brennan, director of SIU, explained in the announcement that every effort is made to recover amounts that have been paid and are determined to have been related to health insurance fraud. However, Highmark doesn’t necessarily recover all such amounts. For example, while judgments are made each year on behalf of Highmark, that doesn’t necessarily mean Highmark receives money equal to the amount of the judgment.

“Our unit works cooperatively with many local, state and national law enforcement groups on a daily basis by sharing ideas, looking at trends and using technology to combat health insurance fraud,” Brennan continued.

He also serves as as secretary for the National Health Care Anti-Fraud Association, which comprises the anti-fraud units of 85 private health payers and the entire spectrum of federal and many state law enforcement agencies.

“According to William Mahon, president of the Washington- based National Health Care Anti-Fraud Association, health care fraud costs American consumers $130 billion annually,” said Highmark’s bulletin..