Federal health agencies estimate that 3-10% of all insurance claims are fraudulent. Some insurance companies, like independent Blue Cross Blue Shield provider Highmark, Inc., have created a Special Investigations Unit (SIU) to track down people who try to process fraudulent claims.

Highmark recently busted a band of chiropractors who, with the help of insured "patients," bilked several insurance companies out of millions of dollars. With the help of a business intelligence application called FIRST, Financial Investigation Reporting System Tool, Highmark discovered fraudulent activity and claims processing related to three Pittsburgh chiropractors and dozens of "patients." Now, nearly 50 people insured by Highmark face prosecution for allegedly receiving kickbacks from the chiropractors involved.

Highmark's Special Investigative Unit (SIU) uses FIRST to track patterns of treatment or billing that do not match up with normal cycles. "We rely heavily on the use of databases implemented on Teradata servers to help us retrieve, process and store data quickly and efficiently," explains Shawn McNelis, Highmark's vice present of health care informatics, research and analysis.

As an extension of the SIU team, Highmark's data warehouse constantly searches for fraudulent activity, summarizes and analyzes data, and then shares the BI reports with SIU agents. Once the possibility of fraud is detected, Highmark's SIU team builds a case based on data quality. McNeils says Highmark realizes a substantial return on investment with its BI capabilities and fraud detection.