Fraud, Waste, and Abuse: Provider Routine Audit Investigations

Highmark Wholecare’s Financial Investigations and Provider Review (FIPR) Team performs annual risk assessments to identify Fraud, Waste, and Abuse (FWA) occurrences and high-risk specialty services. Specialties for review are outlined in the annual FWA Audit Plan based on schemes identified by the Office of Inspector General (OIG), National Health Care Anti-Fraud Association (NHCAA), audit history, outliers from data analysis, and risk assessments. Once the specialties are selected, the Special Investigations Unit (SIU) will conduct provider routine audits as part of the FWA Audit Plan.

In addition to reducing fraud risks, routine audits help ensure proper payments to providers and compliance with contractual and regulatory requirements. Routine audits follow the progressive audit protocol which includes discovery reviews, expanded/full sample reviews, provider disciplinary actions such as Corrective Action Plans (CAPs), and referrals for credible allegations of fraud.

Next Steps

If selected for an audit, you will receive a letter from a SIU Investigator requesting medical records. If we request medical records, the provider must share copies of those records at no cost to Highmark Wholecare, and all required documentation must be submitted, including medical, financial, or administrative records. Once the audit is complete, a findings letter will be sent to providers. Providers could be asked to complete a CAP with a possible overpayment. The Investigator assigned to the case can be contacted for further assistance.

For more information on our FWA audits and investigations, please refer to the Medicaid and Medicare Provider Manuals.