In mid-October 2022, the United States filed a Complaint in Intervention against Cigna Corporation and its subsidiary Medicare Advantage Organizations (collectively, Cigna), seeking damages and penalties under the False Claims Act for submissions of false and invalid patient diagnosis codes to artificially inflate the payments made to Cigna for providing insurance coverage to its Medicare Advantage (MA) plan members.
Cigna owns and operates numerous Medicare Advantage Organizations (MAOs) that administer MA plans. Cigna also contracted with vendors (often nurse practitioners) to conduct brief home visits of Medicare Advantage plan members throughout the country for a “360 comprehensive assessment.” During the assessment, the vendor would complete a Cigna form that included a list of a wide range of medical conditions. Cigna’s coding teams would identify diagnosis codes that corresponded to the recorded medical conditions and submit those to the Centers for Medicare and Medicaid Services (CMS) for risk adjustment payment purposes.
According to the Complaint, the reported diagnosis codes were based solely on forms completed by vendors who were retained – and paid – by Cigna to conduct in-home assessments of plan members. The providers who performed the home visits did not perform or order the testing and/or imaging that would have been necessary to reliably diagnose the complex conditions that were reported, but instead relied on the patient’s self-assessment and screening question responses. The diagnoses were not supported by the information that was documented on the form and were not reported to Cigna by any other health care provider who saw the patient during that same year.
Some of the improper diagnoses included chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications. Cigna’s own clinical guidelines require specialized testing for each of those diagnoses. As noted above, despite lack of evidence, Cigna submitted the diagnoses to CMS to claim increased payments and falsely certified on an annual basis that its diagnosis data submissions were “accurate, complete, and truthful.”
The government alleges that Cigna’s primary purpose for the home visits was to capture and record lucrative diagnosis codes to significantly increase the monthly payments it received from CMS. This was even somewhat acknowledged in internal Cigna documents, where it was noted that the “primary goal of a 360 visit is administrative code capture and not chronic care or acute care management.” Additionally, when selecting which plan members would receive home visits, Cigna would target individuals who were likely to yield the greatest risk score increases, and thereby the greatest increased payment.
The providers were prohibited by Cigna from providing any actual treatment during the home visit for the medical condition(s) found. However, despite being barred from providing any treatment, Cigna allegedly pressured the vendors to record high value diagnoses to increase the risk adjustment payments by identifying twelve classes of generic chronic diagnoses that were “often undiagnosed” and encouraging those same diagnoses to be made through trainings and seminars. When a vendor didn’t deliver the expected level of “high value” diagnosis codes, they were given additional training by Cigna.
Cigna also tracked the return on investment of the home visit program by comparing the costs of the in-home visits against the additional Part C payments generated by the increased risk scores.