Cost Containment Programs

Programs That Reduce Medical Costs

Our cost containment programs, services, and partnerships are designed to manage costs. The programs can evaluate the accuracy of charges, negotiate with out-of-network providers for the best possible rates, and provide governance over the charges health care providers submit. It’s part of our commitment to lowering the total cost of health care for all. 

How Our Cost Containment Programs Work

Out-of-Network Protection

Cigna Healthcare^SM has a large network of quality providers and a demonstrated strategy to encourage in-network care. However, on most plan designs, some out-of-network utilization is always possible.

Our Out-of-Network Protection programs work to achieve the best possible rates from non-contracted providers, while ensuring compliance with federal mandates.

Our Network Savings Program (NSP) and Bill Negotiation Services (BNS) can reduce out-of-network costs and provide added savings when health care providers agree to accept discounted reimbursements off of their billed charges. When savings are achieved through the NSP/BNS programs, customers may also avoid the risk of balance billing. 

Payment Integrity

Cigna Healthcare has robust payment integrity programs designed to combat waste within the health care system. We pair data and analytics with our clinical expertise to drive claims payment accuracy, recover potential overpayments, and protect clients from excessive costs.

Learn more about our payment integrity solutions: Pre-Pay Programs and Post-Payment Recovery.

Pre-Pay Programs

Our data science team identifies patterns within our claims data and applies appropriate pre-pay edits to prevent waste and ensure claims payment accuracy. The team then reviews itemized bills and medical records, leveraging clinical and coding knowledge to prevent claims from being paid incorrectly and drive affordability for our clients.

Post-Payment Recovery

Overpayment opportunities are usually identified when additional information that was not available at the time of initial processing is received after the payment was made.

Our overpayment identification and recovery strategy utilizes both internal and external claim review programs. If overpayments are discovered, vendor partners pursue recovery of the overpayment funds. Internal teams analyze root cause of overpayments to prevent them from happening in the future. 

Fraud Investigation

We provide investigation into fraud, waste, and abuse at no additional charge through our Special Investigations Unit (SIU).

Our data science teams apply AI and rule-based algorithms across all benefits to identify potential instances of fraud. Next, our team will investigate these likely fraud cases. After the investigation, we remediate fraud by enforcing correct billing through case-specific actions, which could include settlement agreements, corrective action plans, or litigation.

Additional Benefits of Our Cost Containment Programs

• Direct negotiations with out-of-network providers and facilities
• Behind-the-scenes claim analysis allows employers to be hands off
• Never charge a fee unless the programs are successful