Cigna goes to great lengths to ensure that our providers—doctors and other health care providers—are reputable and are able to provide quality care. However, there is always a possibility that a provider, or a consumer, will engage in unethical, potentially fraudulent practices. Even a single fraudulent claim can raise the cost of health care benefits for everyone. See how you can help avoid and prevent health care fraud.
What is health care fraud?
Health care fraud is a crime. Health care fraud means to deceive another, like a private insurer, by intentionally misrepresenting or concealing a material fact(s) in order to obtain money or property, such as health care coverage or benefits. Fraud takes many forms and can include direct misrepresentations as well as half-truths and the knowing concealment of facts. Some examples of provider health care fraud are:
- Billing for services not actually performed; billing for drugs not actually dispensed
- Falsifying a patient's diagnosis to justify tests, surgeries, or other procedures that aren't medically necessary; billing for a higher quantity of drugs than was actually dispensed
- 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 copayments or deductibles and over-billing the insurance carrier or benefit plan
- Billing a patient more than the copayment 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, personal information, 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?
- Beware of advertisements or promotions that offer free tests, treatment, or services—especially when the provider requests your insurance information or a copy of your Cigna ID card.
- For those with managed care coverage, question charges exceeding your copayment amount that you're asked to pay by a provider.
- Be careful about disclosing your insurance information. Do not give out your policy numbers to door-to-door salespeople, telephone solicitors, or over the Internet. Protect your Cigna ID card like you would your credit cards. It represents your benefits.
- Compare your Cigna Explanation of Benefits (EOB) and/or your medical prescription drug receipts with your records. Are the dates of service correct? Were the services actually performed?
- 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 Unit (SIU) is responsible for minimizing Cigna's risk of health care fraud. The SIU partners with Cigna's Customer Service Claim Centers and others to help identify suspicious claims, stop payments to fraudulent providers, and punish wrongdoers.
The SIU also works with state and federal law enforcement, regulatory agencies, and other insurance companies to detect and prevent health care fraud and assist in the pursuit of restitution and/or prosecution of health care fraud offenders. The SIU staff includes trained professionals with expertise in investigations, health care, claims processing, law enforcement, and accounting.
- Call the Special Investigations Unit Fraud Hot Line at 1 (800) 667-7145
- Email the Special Investigations Unit at SpecialInvestigations@cigna.com
- Write to us:
Cigna Special Investigations Unit
900 Cottage Grove Road W3SIU
Hartford, CT 06152
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