The Justice Department sued Cigna for allegedly collecting tens of millions of dollars in Medicare excess payments by exaggerating members’ illnesses.
U.S. Attorney for the Southern District of New York sued Cigna on Friday in the Central District Court of Tennessee and accused Cigna of violating the False Claims Act by reporting their Medicare Advantage members sick. than them. The lawsuit alleges that between 2012 and 2019, Cigna hired medical professionals to visit patients’ homes and falsify medical conditions to increase the revenue the company generated from taxpayers.
The Justice Department announced it plans to intervene in an ongoing whistleblower lawsuit related to Cigna’s Medicare Advantage practice in August. Many, but not all, of the charges in the Justice Department case mirror those from the whistleblower case, filed in 2017 in the United States Southern District Court for the Southern District of New York. . The whistleblower alleges that Cigna improperly billed the federal government $1.4 billion. Federal prosecutors accused the insurance company of charging the Centers for Medicare and Medicaid Services “tens of millions” of dollars.
“Cigna has obtained tens of millions of dollars in Medicare funding by submitting false and invalid diagnoses to the government for members of its Medicare Advantage plan,” said US Attorney Damian Williams. know in a press release. “Cigna knows that, under the Medicare Advantage reimbursement system, it pays more if its plan members appear to be sicker.” The government did not specify how much damage it is seeking.
A spokesperson for Cigna will vigorously defend its Medicare Advantage business against these allegations.
CMS pays a flat fee to health insurance companies to manage care for Medicare Advantage enrollees. CMS determines that fee in part based on the number and severity of medical conditions suffered by the patient. Regulators developed this methodology to discourage insurers from cherry-picking healthy Medicare enrollees. But the policy also creates an incentive for carriers to capture as many patient conditions as possible through chart review, home health assessments, primary care visits, and other methods. other.
CMS spent $321 more per Medicare Advantage enrollee than it would if the same Medicare-insured beneficiary charged for the service in 2019, according to analysis by the Kaiser Family Foundation.
According to the Justice Department, Cigna hired nurse practitioners to visit members’ homes with the primary purpose of collecting and recording lucrative diagnostic codes to increase payments. The government alleges Cigna banned these clinicians from providing patient care. As a result, they did not perform or order the testing or imaging that would have been necessary to reliably diagnose the reported conditions, prosecutors charged.
According to the lawsuit, these doctors diagnosed common illnesses such as chronic kidney disease, congestive heart failure and rheumatoid arthritis. The government accused other doctors who saw those patients the same year of not reporting similar illnesses.
Medicare Advantage providers are being closely monitored for these practices across the board. Federal authorities have also sued Elevance Health, formerly Anthem, and UnitedHealth Group for allegedly overpaying for Medicare Advantage. These cases are ongoing.
