In early August 2020, the United States Department of Justice (DOJ) filed suit against Cigna, alleging that Cigna used a primary care program launched in Medicare Advantage to boost its risk scores.
The program, known as the “360 Program,” was launched in 2012 by Cigna’s HealthSpring Medicare Advantage subsidiary and encouraged in-network primary care providers to offer enhanced annual wellness visits (“360” visits) that included an updated health risk assessment, detection of cognitive impairments, and discretionary advance planning services as requested by the patient.
Cigna claimed the goal of the 360 Program was to identify gaps in patient care, because many Plan Members were not visiting their primary care physicians for an annual physical exam because Medicare would not cover the cost. As a result, they claimed serious health conditions were not being detected and that by using the 360 visits, primary care physicians would be able to diagnose and treat the health conditions, thereby improving the quality of care.
However, the DOJ alleges that it was actually used to collect data that then helped to identify health conditions that could raise risk scores and therefore, monthly capitated payments from the Centers for Medicare and Medicaid Services (CMS). To raise the risk scores, senior executives at HealthSpring created a system for targeting Plan Members who were most likely to have the highest potential for risk score and revenue increases. Analysts used a data-mining tool to search medical histories and then organize the Plan Members into different propriety categories, with chronic disease member and Plan Members who had never received a 360 exam were given the highest priorities.
Providers were also given a special form for the 360 visits, a “360 Comprehensive Assessment” form, that did not require the provider to state whether the information was derived from Collected Health Information or Clinical Data, which could have led to inaccurate diagnoses.
The complaint also indicated that Cigna offered participating providers a $150 bonus per completed 360 visit, if a certain volume of visits was met. Providers were also paid $1,000 for every 360 training they attended. The purpose of the 360 training seminars was to teach primary care providers how to leverage information obtained from the visit to find high revenue diagnoses.
“Cigna-HealthSpring intentionally misrepresented these health conditions as part of a widespread scheme to coax CMS into paying a higher monthly capitated rate on behalf of Medicare beneficiaries enrolled in Cigna-HealthSpring’s Medicare Advantage plans,” the lawsuit alleges. The lawsuit notes that the program was designed to capture “as many diagnoses as possible” and CMS overpaid on more claims derived from more than 375,000 360 visits.
This recent lawsuit follows a lawsuit filed earlier this year against Anthem that alleged that the insurer failed to delete inaccurate diagnoses codes in its chart review program. Those actions boosted Medicare Advantage risk scores. The DOJ has been investigating the MA risk adjustment protocols of major insurers in recent years, so it is possible that similar lawsuits are still to come.
Cigna plans to defend against the allegations, saying, “We are proud of our industry-leading Medicare Advantage program and the manner in which we conduct our business. We will actively defend Cigna against unjustified allegations.”