AI Solutions for Healthcare

By Kurt Spear, Vice President of Financial Investigations and Provider Review, Highmark, Inc.

The COVID-19 pandemic has had a major impact on the lives of Americans – a recent CDC report from April 2022 shared that about 60% of U.S. adults and 75% of children in the United States have experienced COVID-19. And it’s not a secret that healthcare providers are among those most affected during the pandemic, faced with large volumes of patients, staffing shortages, excessive billing of labs, inaccurate lab work codes, and much more.

How can we as an industry come together, and re-shape the future of healthcare as the former healthcare system as we knew it no longer exists? How can we move forward in minimizing fraud, waste, and abuse (FWA) that has developed as a result of COVID-19, telehealth, lab testing, and virtual healthcare? Here’s what we learned at Highmark when we focused on reducing risk and maximizing visibility within our organization.

Acting against COVID-19-related FWA

At the beginning of the COVID-19 pandemic, we anticipated potential risks from the virus and created a fraud, waste, and abuse task force dedicated to COVID-19. We brought in individuals from across our health plan ecosystem – from hospital networks to law enforcement agents. We put our heads together and identified about 60 FWA risks that we thought we could potentially be susceptible to because of COVID-19. The most common issues we experienced included:

    • The excessive billing of lab tests
    • Incorrect coding of lab work
    • Clinics that were billing for full patient evaluations at drive-thru clinics when only a COVID swab or COVID-19 test was performed
    • Patients being required to join a practice/clinic to get a vaccine

Our risk mitigation strategy was extremely effective: developing a strong risk framework to identify potential risks and then monitoring our data and analytics to influence our decision-making. The analysis was central to our COVID-19 FWA mitigation strategy; it allowed us to make sure that we were in control of the plan and making the best choices for all stakeholders involved – instead of reacting to the pandemic as it unfolded.

Moving forward with increasing visibility for proactive payment integrity

With the success of the task force, we wanted to continue to find ways to lower the risks of FWA that Highmark experiences. The answer? Injecting transparency into our payment integrity and FWA programs and becoming more granular and visible in the work being done on the self-funded group and the provider sides. Examples of this include audit reads, the number of claims audited per provider, provider error rates, and the dollars taken back in error from waste and abuse.

By using data, we can educate the provider so they can learn from errors and mistakes – you may or may not be surprised to know that many C-Suite professionals at large healthcare systems don’t know the extent of errors found in our payment integrity programs. For example, on some of the claims populations we audit, we’ll find error rates of 40% or more. Sometimes, that’s staggering to the hospital systems – they don’t realize there’s that volume of error. How do we help influence and educate health systems to bill and code with better accuracy? Continuing to share those results is a start.

I often say that payment integrity programs are like Stretch Armstrong: we get stretched and pulled between protecting our customers’ health care dollars and working with providers to assess claims accuracy in a way that is not overly burdensome, and there’s a tug-of-war there.

What we’re trying to focus on at Highmark is being more transparent about our payment integrity and FWA program. Infusing transparency on both sides is going to help customers and providers understand what we’re doing and where the issues are to ultimately help improve billing and coding accuracy. It’s also important to educate – especially with health systems– so that they can fully understand the extent of errors being found and work to mitigate them going forward.


Kurt Spear participated in Codoxo’s Healthcare Executive Round Table, “Re-envisioning Healthcare In 2022 and Beyond,” along with other industry leaders. To watch, click here. To read our eBook, click here.