Highmark Fights Opioid Fraud, Saving $15M

From Health Plan Weekly

Highmark Inc. is working with federal prosecutors to identify and fight fraud related to opioid abuse and says it saved at least $15 million in 2017 as a result.

According to Highmark spokesperson Leilyn Perri, Highmark’s Appalachia-based coverage area sees very high levels of opioid use and abuse. Fraud related to opioid use and abuse can take several forms, including: Affordable Care Act (ACA) exchange plan enrollment fraud, prescription fraud, doctor-shopping and treatment center/lab fraud.

Highmark’s Financial Investigations and Provider Review department saved it more than $183 million, and close to 10% are savings related to opioid epidemic fraud driven largely from ACA enrollment schemes, designated pharmacy programs and other miscellaneous waste and abuse with treatment centers and labs, Perri says.

Opioid treatment is a target for health care fraud because of the money spent by insured patients, especially on inpatient treatment facilities, Epstein Becker Green attorney Melissa Jampol says. "Whenever there’s potential money being made in the health care industry, you see fraud."

Attorney Andrew Sparks, counsel at Dickinson Wright in Lexington, Ky., suggests that key indicators of a provider engaged in fraud include upcoded office visits, an unusually high number of patients seen in one day, too many lab tests and inappropriate or frequent urine drug screening.

He adds that opioid-related fraud has evolved rapidly even as law enforcement has learned how to shut some of it down. To combat the problem, insurers need to mine their own data.

"If you look at [a provider] and see that every patient’s revenue potential is being maximized," that’s a potential sign of fraud, he says. Insurers should also keep track of providers on their panels who have been investigated or sanctioned by a state medical board.

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