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What is health care fraud?
Health care fraud is a crime. It's committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of health care benefits payable.
Some examples of provider health care fraud are:
- billing for services not actually performed;
- falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary;
- misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery;
- upcoding – billing for a more costly service than the one actually performed;
- unbundling – billing each stage of a procedure as if it were a separate procedure;
- accepting kickbacks for patient referrals;
- waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan;
- billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
Some examples of consumer health care fraud are:
- filing claims for services or medications not received;
- forging or altering bills or receipts;
- using someone else's coverage or insurance card.
Help avoid and prevent health care fraud
- Here are some easy ways you can protect yourself from health care fraud, and keep health care costs down for everyone:
- Ask questions about the services you receive, such as: Why are they needed? What do they cost?
- Fill out, sign and date one claim form at a time.
- Question advertisements or promotions that offer free tests, treatment or services – especially when the provider requests your insurance information or a copy of your Cigna HealthCare ID card.
- In general, be careful about disclosing your insurance information. Protect your Cigna HealthCare ID card. It represents your benefits.
- Compare your Cigna HealthCare Explanation of Benefits (EOB) and/or your medical bills with your records. Are the dates of service correct? Were the services actually performed?
- For those with managed care coverage, question charges exceeding your copayment amount that you're asked to pay by a provider.
- Let us know if a provider has a practice of waiving copayments or deductibles.
- Report suspected fraud to Special Investigations.
Cigna is working to minimize health care fraud
Our Corporate Audit Department's Special Investigations (SI) team is responsible for minimizing Cigna's risk to health care fraud. The SI team partners with Cigna's Customer Service Claim Centers and others to help identify suspicious claims, stop payments to fraudulent providers and punish wrongdoers.
The SI team also works with state and federal law enforcement and regulatory agencies and other insurance companies to detect, prevent and prosecute health care fraud. The SI team includes trained professionals with expertise in investigations, health care, nursing, law enforcement and accounting.