Case Study: Highmark achieves rapid fraud detection and increased recoveries with FICO Insurance Fraud Manager

Leading healthcare payer tightens grip on fraud with automated detection analysis

Highmark, one of the largest commercial healthcare payers in the U.S., needed to tighten detection of provider fraud, abuse and billing errors across massive, legacy claims repositories. Its existing rules-based screens and investigator-driven leads missed complex, multi-claim patterns, so Highmark sought an automated solution to support deeper postpayment analysis and a future prepayment scoring capability.

Highmark implemented FICO Insurance Fraud Manager—Healthcare Edition alongside a homegrown web inquiry system (FIRST) and centralized data feeds (140M claims, 4M members, 20,800 providers). Within months investigators flagged 83 new fraud cases; recoveries from just two cases more than paid for the software, top-200 provider reviews uncovered 39 previously unknown cases and validated 44 existing ones, and peer-comparison analysis added 19% more potential fraud dollars—delivering rapid ROI and approval to extend to prepayment detection.

Highmark

Denny Latsha

Project Manager