Integrated claims data helps detect and deter fraud, waste and abuse

At Cigna, having health care benefits integrated together in one place means so much more than customer convenience – a combined ID card, one online resource and a single point of contact. Our ability to connect insights helps paint a picture about an individual’s health. When we fit together our broad collection of data points, we can spot irregularities. We can identify possible fraud, hone in on wasteful prescribing, and determine risk for medication misuse or abuse. We can then intervene and advocate for our customers’ best health.

Cigna Fraud, Waste and Abuse (FWA) programs help identify and mitigate fraudulent activity at both the prescriber and pharmacy level.
The market-leading analytics and investigative work of our FWA programs are like a searchlight - always scanning. Cigna’s FWA investigations are estimated to save hundreds of millions of dollars for clients by thwarting unnecessary and/or potential fraudulent healthcare procedures and prescriptions.¹ This behind-the-scenes work is all offered at no additional cost to our clients.

Using multiple sources of data, complex analytics and specialized investigative capabilities, Cigna’s Special Investigations Unit (SIU) quickly identifies risk while working to investigate and resolve potential fraud on behalf of our clients and customers. We proactively monitor claims, healthcare providers and pharmacies.

One particular FWA investigation led to cost avoidance of over $2.9M.¹
The savings came as the result of a jolting pharmacy claims analysis. It showed a spike in prescriptions for certain high-cost brand-name drugs – a jump from 0 to 432 claims in a one-month period. The claims were associated with 60 Cigna customers alleged to have visited a specific health care provider in California. However, the customers had no associated medical claims to warrant the drugs prescribed.

SIU researched the issue and discovered the prescriber engaged in a fraudulent scheme. The investigation revealed that certain pharmacies had agreed to pay the prescriber a $200 cash incentive for writing these high-dollar prescriptions.

Thanks to their investigative work, SIU successfully:

• Blocked the provider’s prescribing to prevent any further exposure to the fraud scheme.
• Reported this case to the California Medical Board and to law enforcement.
• Removed associated pharmacies from the Cigna pharmacy network.

As we strive to stop medication misuse and abuse, our drug utilization management (UM) checkpoints also help prevent ineffective or unnecessary drugs.
Our drug UM process is in place as a standard offering. It helps to ensure customers receive the right drug at the right time to meet their health and safety needs. We focus on total medical cost and customer safety. We proactively review integrated data on new and emerging drugs and apply these UM practices:

• Quantity limits (QL): Help ensure clinically appropriate dosing and duration of use to reduce waste and potential stockpiling of medication.
• Prior authorization (PA): Helps ensure clinically appropriate medication use for improved safety and positive health outcomes.
• Step therapy (ST): Helps ensure use of clinically effective first-line medications before considering coverage of second-line alternatives – for improved affordability.

We further optimize UM, and client pharmacy benefit spend, in these ways:

• Real-time benefit check – Cigna's real-time benefit check makes it possible for a customer’s specific pharmacy benefit and formulary information to be included in their Electronic Health Record (EHR) at the point of prescribing. This provides prescribers and customers line of sight of what a medication may cost, if it requires UM (such as a PA) and if there are alternatives to save and/or to avoid UM. We see 50 to 75 percent of customers move to an alternative medication when we provide clinical and cost information to prescribers.²
   
• Electronic Prior Authorization (ePA) – This is an electronic transmission of information between the prescriber, and payer, to determine whether or not the PA is granted. If a PA is required for a medication, the provider will be able to initiate and obtain a response in real time. In fact, ePA allows doctors to submit a PA in less than one minute.³
   
• Streamlined PA with Cigna Rx Claim Connect – Cigna Rx Claim Connect uses medical, pharmacy, and lab data to avoid the need for a PA.  When the demographic and clinical data satisfies the PA criteria, the claim is paid instantly, providing the customer immediate access to their medication.  Improved speed-to-therapy means a positive experience for both the customer and the prescriber, and better health outcomes. Approximately 56 percent of PAs are avoided through Rx Claim Connect.⁴

Our Medication Safety Program works to pinpoint and intervene on medication abuse - results include a 16 percent reduction in opioid overdose rates since 2018.⁵
We use claims data to monitor prescribing patterns. We identify high-risk individuals and send a secure report/letter to their prescriber(s). The letter explains the detected risk factors for opioid-related overdose and highlights all the risk-reducing support resources available: coaching, behavioral support, as well as opioid and chronic pain case management. We avoid sending alerts about customers who have a known clinical need to remain on multiple narcotic medications.

With Cigna inMynd^SM, we connect pharmacy customer engagements with data and clinical care teams, and then guide at-risk customers and their families to health education, online resources and counseling support. As part of this work, we offer an integrated solution for customers taking multiple psychotropic drugs. We examine six months of retrospective pharmacy and medical claims data. This helps trigger support for identified individuals.

Cigna’s programs to identify and prevent improper prescribing and/or medication misuse are automatically part of our integrated benefits at no additional cost. Our goal is to protect the health, well-being, and sense of security of our clients and customers.

For more about Cigna’s actions to reduce opioid overdoses, please visit our pain resource hub: Cigna.com/helpwithpain

1. Cigna National Book of Business analysis. November 2020.
2. Cigna National Book of Business analysis of step therapy activity, October 2018 – performance dependent on therapeutic class – subject to change.
3. Cigna National Book of Business analysis of ePA program, full-year 2018.
4. Based on most recent results of Cigna Rx Claims Connect reported May 2019.
5. Opioid overdose rate measured in triple integrated populations in five target markets from 2019-Q2 2021 over 2018 baseline.

* Depending on the customer’s coverage, they may or may not have access to Behavioral Health case management. Customers are advised to check their plan materials, or call the number on the back of their Cigna ID card, to find out what behavioral health services their plan covers.