The Cigna Group agreed to pay $172 million to resolve allegations that it submitted—and failed to withdraw—inaccurate and false diagnosis codes for its Medicare Advantage Plan enrollees so payments from Medicare would increase.
The Medicare Advantage Plan Program allows beneficiaries to opt for covered benefits through private insurance plans, and the Centers for Medicare and Medicaid Services pays the plans a fixed monthly income for each beneficiary.
The fixed amount paid into the plan is adjusted based on what health care is needed for the beneficiary, regulators said. To determine the amount, "risk adjustment" data is collected and is used to give more money to those who are expected to have higher health care costs.
Federal prosecutors alleged that Cigna violated the False Claims Act when it submitted wrong patient-prognosis data to bring up the payments into the beneficiaries' plans.
"Over half of our nation's Medicare beneficiaries are now enrolled in Medicare Advantage plans, and the government pays private insurers over $450 billion each year to provide for their care," Deputy Assistant Attorney General Michael D. Granston of the Justice Department's Civil Division said. "We will hold accountable those insurers who knowingly seek inflated Medicare payments by manipulating beneficiary diagnoses or any other applicable requirements."
Spokespersons for Cigna—Justine Sessions, Meaghan MacDonald, Kelly Matthews and Karla Cutting—did not immediately respond to a request for comment.
Prosecutors also accused Cigna of using forms completed by vendors hired and paid by Cigna to do home assessments.
The company also allegedly submitted or did not delete inaccurate codes for morbid obesity.
The United States additionally contended that Cigna's chart review program identified which diagnoses would result in additional payment.
"Medicare Advantage plans that submit false information to increase payments from CMS show blatant disregard for the integrity of these vital federal health care funds," Christian J. Schrank, deputy inspector general for investigations with the Office of Inspector General for the Department of Health and Human Services, said. "Such actions are an affront to the Medicare program and the millions of patients who rely on its services. Working with our law enforcement partners, our agency will continue to prioritize investigating alleged fraud that targets the Medicare Advantage program."
Emily Cousins
I'm a litigation reporter for Connecticut Law Tribune, covering litigation wins, verdict news, settlements, interesting cases, etc. Contact me with tips at [email protected].