How Highmark Found Excluded Employees in Month One — and Built a Compliance Program That Scales

Exclusion monitoring is not a back-office formality, especially for Highmark, one of the largest Blue Cross Blue Shield licensees in the country. It is a critical compliance function that touches millions of lives, which means that every match matters – and efficiency counts as much as accuracy. When Highmark’s compliance team took a hard look at the manual burden and missed matches that were piling up under its previous vendor, leadership knew it was time for a change. What followed was a full transition to ProviderTrust, a cleanup of years of dormant data, and the immediate discovery of excluded individuals that had gone undetected for an unknown period.

ABOUT OUR CLIENT

Highmark Inc. is one of the largest integrated health delivery and financing networks in the United States. Its exclusion monitoring program spans an enormous and diverse population of employees, vendors, and providers, including the Allegheny Health Network (AHN), a major health system operating under the Highmark umbrella.

CHALLENGE / SOLUTION

THE CHALLENGE

Before ProviderTrust, Highmark relied on a different exclusion monitoring vendor that screened files on a fixed schedule, only once a month. If a file was uploaded late, there was no recourse: that population was simply not screened for that period, creating audit risks and compliance gaps that were difficult to explain or defend.

The even more pressing problem was the volume of potential matches being returned. Every month, Highmark’s compliance team and business area stakeholders across the organization reviewed hundreds of potential matches, the vast majority of which could not be confirmed with certainty.

Because the previous vendor’s data was not precise enough to rule matches in or out, human reviewers had to do the investigative work that the tool should have done. The issue was especially challenging because the process had been distributed across multiple business areas, leaving no guarantee that people reviewing potential matches had the training or context to evaluate them correctly.

“We were reviewing hundreds of potential matches every month, every single month. We had outsourced this across different business areas—and who knows if they were doing it right?” said Highmark’s Manager of Integrated Risk Operations.

Compounding all of this was a data integrity crisis hiding in plain sight. Lists that had been fed into the old system for years had never been audited. The individuals who built the old system and process had largely left the organization. Files were bloated with stale or inaccurate records, which made it impossible to produce reliable reports or accurate pricing estimates, even during the RFP process to find a new vendor.

THE SOLUTION

Following a competitive RFP in 2021, Highmark selected ProviderTrust over other contenders. The Highmark team was drawn to the breadth of the platform’s capabilities, the quality of its data, and the people behind it.

Rather than attempting a single large cutover, Highmark made the strategic decision to onboard its smaller AHN population first. This approach allowed the team to pressure-test workflows, build internal confidence, and demonstrate results before expanding to the full Highmark enterprise.

The transition to ProviderTrust also triggered the long-overdue data cleanup work. The compliance team launched a file attestation process, reaching out to business area owners across the organization to verify the accuracy of their screening lists. While the previous setup had allowed lists to grow unchecked for years, ProviderTrust’s model demanded accuracy, and Highmark’s team used that requirement as leverage to finally engage the right stakeholders.

Unlike the previous vendor’s once-monthly static check, ProviderTrust screens populations on a continuous, ongoing basis. If a file is late or a new entity is added mid-month, the coverage does not lapse. For Highmark’s compliance team, that shift alone resolved a persistent source of audit exposure.

“With ProviderTrust, they’re screened all month. With the previous vendor, they just weren’t as up-to-date, which put us in a bad place some of the time,” said Highmark’s Manager of Integrated Risk Operations.

THE RESULTS

Immediate ROI from Day One

Highmark did not have to wait to see the value of the switch. After the initial AHN upload, the team identified matches that the previous vendor had never surfaced. The reduction in false positives and unconfirmable matches was felt immediately: employees who had been spending significant time manually clearing questionable hits were suddenly free to focus on higher-value compliance work, including refining lists, closing screening gaps, and auditing data accuracy.

“After that first upload, after we cleaned up the initial hits the previous vendor wasn’t identifying—it was immediate,” said Highmark’s Manager of Integrated Risk Operations. “We saw an ROI. My team was like, I can do other stuff. I’m not spending additional time clearing a match for someone whose name doesn’t even match.”

Employee Matches That Had Been Undetected

Among the most striking early results was what ProviderTrust found that the previous vendor had missed entirely. When Highmark onboarded AHN in the first month, a match was identified on an employee—an exclusion that had not been documented or caught under the prior system. When the full Highmark enterprise was onboarded in February of the following year, the same thing happened again: another employee match surfaced in the first month, also previously undetected.

These discoveries had an unmistakable effect on internal stakeholders. Abstract arguments about screening accuracy became concrete. Leadership across the organization understood, in a way that a presentation never could have conveyed, why the investment in better data mattered.

A Scalable Case for Enterprise Expansion

The AHN rollout became the template for the larger enterprise transition. Those results gave Highmark's compliance team everything they needed to move forward with confidence. They had proof of concept, refined processes, and a clear internal narrative. If two matches had surfaced in a smaller population in month one, the case for scaling to more than a million lines of data would have been self-evident.

THE FUTURE

Today, ProviderTrust is monitoring all populations for Highmark and AHN to include their employees, providers, and vendors, and is expanding its reach, to include their dental network and new Blues that have recently been acquired into the Highmark umbrella. What began as a vendor switch has become an ongoing commitment to continuous improvement and a model for how a large, complex organization can bring rigor and accountability to a process that is too often overlooked.

Interested in learning how ProviderTrust can support your organization with always-accurate data?

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