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Fighting fraud with our 360° approach

16 March 2017

Fraud is not a victimless crime. Everyone loses: the organisation, the plan participants, the insurance company and other stakeholders. The detection, prevention and investigation of fraud, waste and abuse is vital in order to keep a medical plan viable through mitigating fraudulent activity and containing unnecessary costs.

We sat down with our Head of the Fraud Investigation Unit, to discuss the evolution of health care fraud detection.

How has fraud developed over time?

Insurance fraud undoubtedly started days after the first insurance product was launched. Fraudsters tend to be very inventive and creative if it comes to adapting to existing prevention and detection measures put in place by insurance companies. Fraud schemes hence change constantly and investigations teams need to adapt to this constant change.

Five years ago, we saw many cases of manual alterations on invoices where someone would claim 180 USD instead of 80 USD by just placing a 1 in front of the 80. Now, with technology being so advanced, it’s fairly easy for an individual with malicious intent and some computer skills to fabricate or alter claims documents with attention to the smallest detail. This makes it very difficult for the untrained eye to differentiate between a real and a false claim.

Nowadays, people are also more comfortable with software applications and online transactions. We notice that new media are becoming very popular among plan participants and health care providers. Digitalisation has so many benefits to its users, but at the same time a small minority might find it more tempting to submit manipulated invoices. As a result of the increased risk of claim manipulation, our team constantly adapts the skill sets and tools needed to effectively detect red flags in online claim submissions.

How does Cigna counter the evolutions in fraud?

We don’t only look at the claim image or document. We have a comprehensive anti-fraud approach with a combination of awareness, pre-payment and post-payment detection, and thorough investigation by a group of experts.

Do you think fraud will be completely eliminated in the future:

Completely eliminating fraud is impossible. Fully eliminating fraud would require companies to hire an army of employees to scrutinise every individual transaction. Our goal is to find a reasonable balance between prevention and detection efforts on the one hand and the risk appetite on the other. While fully eliminating fraud is unlikely, Cigna does aim to strongly discourage fraud with our comprehensive counter-fraud approach.