Case Study: Highmark achieves 263 new pursuable cases and substantial cost savings with FICO Insurance Fraud Manager

FICO health care fraud analytics uncover vast savings for Highmark

Highmark, Inc., a leading Pennsylvania health insurer serving 4.7 million members, needed to dramatically reduce losses and improve operational efficiency by better detecting and preventing fraud, waste and abuse in submitted claims. Existing rules‑based reviews, manual investigations and hotline tips were missing cases and limiting recoveries.

Highmark implemented FICO Insurance Fraud Manager—predictive provider and claims scoring models with enterprise case management—to automatically score roughly 250,000 claims per day and prioritize high‑risk items for review. In the first 13 months a five‑person team opened 263 new pursuable cases (including 43 multi‑provider cases), uncovered savings that outpaced team overhead by about 17×, identified errors and policy weaknesses for correction, and delivered substantial operational and financial returns.

Highmark

Denny Latsha

Project Manager