Fraud, waste, and abuse (FWA) requires constant vigilance from health plans and a robust payment integrity program. From the usual compliance requirements and coding accuracy for most commercial plans, to the added layers needed for Medicaid plans with state regulations and mandates, there are a lot of details to monitor. Yet many improper claims can still be missed for various reasons, from insufficient staff and disparate record systems to incomplete data sets and prompt-pay deadlines. The volume of claims can be a challenge for health plans with smaller internal teams, especially when trying to intervene before payment. Therefore, bringing in extra support helps speed along the process of catching FWA, whether simple mistakes or signs of nefarious activity.

Looking for prepay support for its own internal special investigations unit (SIU), Highmark Wholecare enlisted the help of Cotiviti’s Claim Pattern Review solution.

Seeking support for claim volume

Highmark is collectively the fifth-largest overall Blue Cross and Blue Shield affiliated organization in the United States, with 7 million members and 154,000 in-network physicians. Highmark Wholecare, a subsidiary of Highmark Inc., is a large northeast health plan. Based in Pennsylvania, Highmark Wholecare is a community-based, mission-driven organization that serves more than 410,000 members through Medicaid and Medicare health plans focused on delivering whole person care. Their network includes more than 30,000 providers.

"We’ve been a Cotiviti client for years and have always been impressed by the flexibility and comfortability we have with the people we work with."

A Cotiviti client for years, Highmark Wholecare approached Cotiviti for help with monitoring claim volume for patterns of improper billing that could be managed before payment. With an SIU of seven people, Highmark was seeking a solution that would neither displace these team members nor cause them more work to vet FWA leads. 

“We were looking for a way to scale up our claim review efforts for FWA and we were excited to add this solution for additional support,” says Jennifer Putt, manager of financial investigations and provider review. “We’ve been a Cotiviti client for years and have always been impressed by the flexibility and comfortability we have with the people we work with.”

Cotiviti recommended Claim Pattern Review, a prepay FWA solution that helps maximize return by preventing the payment of claims found to be part of a pattern of waste or abuse. Claim Pattern Review supports staff productivity by proactively identifying potential bad billing behaviors and helps SIUs build cases against those committing fraud. Highmark was excited to explore the possibilities of using Claim Pattern Review for scaling up FWA prevention efforts.

Implementing a new solution

In getting started, Highmark and Cotiviti came together to identify key objectives and exclusions. Claim Pattern Review started to take shape as the team installed necessary software, held implementation calls, and pulled together IT teams. 

After implementing the solution, Highmark took care to inform providers 30 days before going live of how their claims would now be processed and updated them every 90 days of any new developments. The plan started with a single provider in June 2023 and gradually added more, eventually scaling the number of providers up to more than 40.

Achieving results from Claim Pattern Review

Savings from Claim Pattern Review have thus far totaled more than $1 million, with more than $100,000 from durable medical equipment (DME) claims alone—and these savings continue to grow. 

"Claim Pattern Review is really a benefit to my team. We’re looking at providers, coding, and billing, and are able to mitigate any risk of fraud, waste, or abuse."

Highmark realizes high accuracy rates from the solution and a low provider appeals rate on Cotiviti claim decisions of just 8%*. Currently, the health plan approves 90%* of Claim Pattern Review findings, and approves providers to place on prepay review as well as denial recommendations.

“Our overall experience with Cotiviti has been fantastic,” continued Putt. “Claim Pattern Review is really a benefit to my team. We’re looking at providers, coding, and billing, and are able to mitigate any risk of fraud, waste, or abuse. On the back end, since we’re a smaller team and we’re monitoring for FWA every day, we’re now able to pull suspicious activity and flag providers for Cotiviti to add to Claim Pattern Review to supplement our own efforts. Cotiviti is able to provide additional insights to add to and enhance our process. We’ve been able to make additional law enforcement referrals and to perform some additional surveillance efforts.”

*According to Cotiviti data collected in August 2024.