Of the $245 million Highmark saved through the program in 2021, about $152 million was related to employer-sponsored insurance, $49 million was from the Blue Card program, which provides Highmark customers access to national Blue Cross Blue Shield networks, $19 million came from Medicare Advantage, $16 million came from Affordable Care Act exchange plans and $9 million came from the Federal Employee Program. Most of 2021’s savings—$184 million—were related to fraud, waste and abuse in Pennsylvania. Another $25 million were related to cases in West Virginia , and $23 million were in Delaware.

Highmark’s program has been in place for at least 15 years, and it saves around $200 million each year, Spear said.

Highmark’s annual return on investment is about eight to one for its roughly 80-person fraud team, he added. Highmark drew $18 billion in revenue in 2020.

Eight to one is a “very good” return on investment for a fraud program, said Adam Block, assistant professor of public health at New York Medical College who also runs a return-on-investment consulting practice. Four to one is the “bare minimum” threshold that makes a fraud program worth continuing, he said.

It’s no wonder Highmark makes its results public: They demonstrate value the company provides to consumers, Block said.

“When you are weeding out fraud from the claims process, you’re reducing premiums, you’re showing the providers not to try it with your organization, otherwise you’re doing to get called out on it,” he said. “I ‘m not surprised they would release a press release because there is really nobody in favor of fraud and abuse.”

That said, it’s an open question whether all the items Highmark called out are actual examples of fraud, waste and abuse, Block said. Say a provider does a lot of magnetic resonance imaging for low back pain. Even though the practice is not supported by scientific evidence, that doesn’t mean it’s not billable if a provider believed it was necessary, he added.

“It could be a legitimate expense that gets picked up by a fraud, waste and abuse detector and claims get denied but the utilization was not fraudulent,” Block said.

Spear touted Highmark’s use of artificial intelligence to identify potential examples of fraud, waste and abuse. The insurer also has a team of medical professionals and coders that review any claim that’s flagged by the program.

AI and machine learning are valuable tools, but West Monroe’s Ray said these cases still involve actual humans going through and reviewing the claims.

“These tools are, I think, important, but the idea of ??AI is no different from the idea of ??being able to identify things that need review,” he said. “Nothing happening through AI is creating an activity that is completely human-less through fraud, waste and abuse.”