Instructions The final paper is expected to be a minimum of 20 pages and should includethe following: An introduction that gages the significance and value of the topic. A review of the literature...

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    A Detailed Overview of Cigna as Medicare Advantage Service Provider
Table of Contents
Executive Summary    1
Introduction    2
Statement of Problem    3
Research Methodology    6
Research Questions    6
Literature Review    7
Summary and Findings    13
References    17

    
Executive Summary
The insurance sector of United States has grown over the past few years rapidly. There are several insurance service providers who have excelled in their services. Medicare Advantage is the prime selling insurance product by agencies across all states in America. The following is an analysis of the competitive advantage taken by Cigna, one of the largest insurance agencies operating in United States over others. The research is conducted by keeping in line that fraudulent activities have increased in the recent years as well, causing the compliance management system of the companies confront several unwanted challenges. The paper also highlights how Cigna has created that precisely directed audit system to assist its clients in terms of having the perfect state of insurance. The preventive measures about preventing fraud to happen are also reviewed in the light of available literature.
Introduction
    The core essence of healthy competency in business is to establish quality of service that should be rendered to consumers. In fact, the scale of competency is analyzed by the features, provisions, product reviews as well as the durability of a particular marketing segment for the company in general. These dimensions of analysis justify how far a company or its product can survive in the market. One of the top growing sectors in the world, healthcare products also go through the same competency level.
In terms of calling them as ‘products’, the criteria of healthcare items is not fixed with one area; there are multiple angles from which, the healthcare products quality of services provided by the healthcare service providers as well as the adhering to the norms set by the government builds up the durability of a particular healthcare product. The same applies to the insurance products existing in the market of United States healthcare industry.
    Insurance policies are the carriers of financial security provided to the patients in terms of having their quality of care approved by some credible agency. Medicare and its related products have taken command of the overall insurance market in American healthcare segment. Medicare and Medical advantage are the insurance schemes that are liberally offered by the insurance agencies in the name of quality hospitals. However, not all the companies make good and positive commitments to their consumers, when it comes to the practical ground of reimbursing or disbursing a particular policy of Medicare.
Instances of fraud, false commitments and non-professional pursuit of ethical behavior by the insurance agencies have been emerging out of nowhere in the recent years, causing panic and confusion in the minds of the common consumers like how and when they are supposed to determine personal and family insurance. These frauds lead to misleading provisions, wrong assessment of the client based on their requirements and, therefore; making them victimized at the time of disbursal of their Medicare policies.
The following is an analysis of Cigna Medicare, a leading agency that is providing five star services to the clients by offering them quality Medicare provisions. The research direction is also committed to highlight some of the major problems that remain as undercurrent in the insurance sector and how they lead to problematic situations in future for the clients.
Statement of Problem
    While choosing for the insurance plans, a great deal of complications surge at times out of nowhere before the person expecting them. In fact, the problem begins with the wide range of insurance plans available at various private and government service providers. Also, the fact leads to the outcome that the person willing to take any insurance plan at times sees the bright side of the provision i.e. he chooses the best suitable one for him but this choice becomes hard to make when there is a variety of offers before him. In such a time, the role of an agency providing insurance services becomes important because it is the part of the agency to explain plans and assist the client to the best of their potential so that he or she can choose the best one out of many for him or her. In the same way, it is the primary duty of the agency to save client from being victimized by fraudulent activities of falsifying notions existing in the market. Misleading, non ethical behavior and sharing the private information of client are some of the examples of frauds being done in insurance sector.
Medical insurance is one of the top trends in healthcare service product selling in the market apart from private drug plans taken by patients. Fraud in this category happens when half truth is spoken to the client, willing to accept some kind of insurance plan. In American context, the insurance based frauds have been doubled in the recent years. Concealing of facts, misleading the clients as well as taking up their policy by fraud activities is done widely across nation. The problem lies in the centre of insurance services itself; the service providers are many, approved by the central and state government to run their business and it gives an opportunity to the frauds to clone their services by having a different name. This cloning allows the frauds to access the common database of patients and they conduct regressive searches to take out their private information.
    Further, the problems initiate when such patients/vulnerable customers are approached by such fake service providers. The clients are served with ludicrous offers made in their favor which are not credible. However, because of their tempting nature, the plans are accepted by the vulnerable customers without checking the details. The fraud is done in the light of the information shared by the client as well as through some loopholes existing in the system. The issue of fraud does not end up with fake insurance service providers merely; some of the approved insurance service providers also pose complex situations before their customers. Every citizen has the right to choose the best plan for his or her insurance, however, when it comes to practical grounds, they are strangled in their thoughts by the so called insurance agents. They are not given proper explanations so that they can come up with some strong insurance provision out of many, as presented by Medicare.
    In exemplifying some of the instances of frauds done by insurance service provides, it can be inferred as the billing procedure is made ambiguous; either the billing of drugs and premium filled is not performed or it is not dispensed to the client—in some of the cases, the ‘adjustment in billing is done so that the client’s will is exclusively entertained. In other words, the patient and the service provider both enter in a contract that is implied; the client would not demand for the billing dispenses and at the same time, the service provider would get an opportunity to save the taxes to be paid to the government directly. This is the first and foremost fraud level happening these days and it needs immediate attention.
    The second state of fraud happens when the falsification of the diagnosis is done in order to increase the drug and surgery, whichever are necessary, based expenses. The billing is wrongly done which puts extra burden over the insurance policy of the client. Again, it is more of a kind of mutually agreed bond between the insurance service provider and the care service provider i.e. the hospital in which, the client ahs reached for treatment. At times, misrepresentation of the services is done to increase billing which is also not ethical practice and most of the times, service provider of insurance as well as the care service provider are mutually involved in this fraud. Sometimes, up-coding is done which is the process through which, costlier services than actual ones are charged which were actually not performed over the client.
    Additionally, the insurance and care service based frauds are not limited to one end of insurance service provider only; the customers too attempt to do the fraud. For example to claim extra benefits, fake receipts of treatments are generated and presented. Wrong billing is shown to the insurance agency to deceive them about the treatment procedure. Sometimes, someone’s insurance card is used to make sure that fraud is made third party; the insurance agency is deceived by presenting wrong facts over an issue of care which does not actually exist in the real client but in a fake one.
    In the light of the above mentioned problems it can be stated that insurance services like Medicare are designed to ease the process of care for the patients. However, due to the existing loopholes, the overall procedure of care is compromised either by the insurance agencies, care service providers or even by the patients taking the benefits in an inappropriate manner. Therefore; it becomes necessary to examine the problems and how one agency like Cigna can offer the best provisions so that the frauds can be avoided. The following research methodology is used to conduct wide research over the topic:
Research Methodology
    In order to approach the research topic precisely, a wide variety of qualitative sources has been sued in the current search. The method of search is essentially kept on qualitative norms because of the nature of the subject. The preventive measures taken up by Cigna and the scale of maintaining competitive business advantage over other is put to analysis in the resources. The sources are taken based on the overall quality of the findings presented in them. Some of the sources are used as they represent how Cigna operates in insurance sector while the others are applied analysis of the insurance procedure in general. There are some specific findings that are also included in the investigation...