Recently, the Cigna Group agreed to pay more than $172 million to resolve allegations that it violated the False Claims Act by submitting – and failing to withdraw – inaccurate diagnosis codes for its Medicare Advantage Plan enrollees, in an attempt to increase payments received from Medicare.
The $172,294,350 settlement stems from several separate claims, including claims filed in the Eastern District of Pennsylvania and the Middle District of Tennessee. Cigna owns and operates Medicare Advantage (MA) organizations that offer MA plans to beneficiaries around the United States. In the cases at hand, the government alleged that Cigna submitted inaccurate patient diagnosis data to the Centers for Medicare and Medicaid Services (CMS) to receive inflated payments from the agency and failed to withdraw the inaccurate diagnosis data and/or repay CMS. The government also alleged that Cigna falsely certified (in writing) to CMS that the data was accurate and truthful.
The United States alleged that for payment years 2014 to 2019, Cigna operated a “chart review program” in which it obtained medical records from health care providers that documented services they previously rendered to Cigna’s MA plan beneficiaries. Cigna hired individuals to review the charts to identify medical conditions that were supported by the charts and then assign diagnosis codes for the conditions. The results of the chart reviews were then used to submit those additional diagnosis codes to CMS that the health care providers had not technically reported for the beneficiaries, to obtain additional CMS payments.
However, the charts did not substantiate some of the diagnosis codes that were reported by providers and submitted by Cigna to CMS. Cigna did not withdraw the inaccurate diagnosis codes, which would have required the company to reimburse CMS for improper payments made. The United States, therefore, alleged that Cigna used the chart reviews as a way to seek additional payments from CMS while improperly failing to use the same results when they provided information about instances where Cigna was overpaid.
Additionally, the United States alleged that Cigna reported diagnosis codes to CMS that were based just on forms completed by vendors that were retained and paid by Cigna to perform in-home assessments of MA plan members. The health care providers performing those in-home visits did not perform (or even order) the diagnostic testing/imaging that would have been required to reliably diagnose the complex conditions reported on the forms. The in-home providers were also often prohibited by Cigna from providing any treatment during the in-home visit for the conditions that were reportedly found. The diagnoses at issue on the forms were typically not supported by the information on the forms completed by the vendors and were also often not reported to Cigna by any other health care provider of the patient. Even still, Cigna submitted the diagnoses to CMS to claim increased reimbursement amounts and falsely certified to the agency that the diagnosis data submitted was “accurate, complete, and truthful.”
The United States also alleged that for payment years 2016 to 2021, Cigna knowingly submitted and/or failed to delete/withdraw inaccurate and untruthful diagnosis codes for morbid obesity to increase payments received from CMS. Medical records for patients that are diagnosed as morbidly obese often include one or more BMI recordings and individuals with a BMI of less than 35 cannot be diagnosed as morbidly obese. Cigna, however, submitted – or failed to delete – inaccurate and untruthful diagnosis codes for morbid obesity for individuals without a BMI of 35 or higher, thereby dishonestly increasing their payment amounts received by CMS for these beneficiaries.
In addition to the monetary settlement, Cigna entered into a five-year Corporate Integrity Agreement (CIA) with the United States Department of Health and Human Services Office of Inspector General (HHS OIG), requiring the implementation of multiple accountability and audit procedures.
“For years, Cigna submitted to the Government false and invalid diagnosis information for its Medicare Advantage plan members. The reported diagnoses of serious and complex conditions were based solely on cursory in-home assessments by providers who did not perform necessary diagnostic testing and imaging. Cigna knew that these diagnoses would increase its Medicare Advantage payments by making its plan members appear sicker,” said Damian Williams, United States Attorney for the Southern District of New York. “This Office is committed to holding insurers accountable if they seek to manipulate the Medicare Advantage Program and boost their profits by submitting false information to the Government.”
“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,” stated Christian J. Schrank, Deputy Inspector General for Investigations with HHS-OIG. “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.”
A copy of the Eastern District of Pennsylvania agreement can be found here and a copy of the Southern District of New York/Middle District of Tennessee settlement agreement can be found here.