Cigna Accused of Medicare Advantage Fraud, Department of Justice Sues

Cigna is charged with falsifying the health conditions of its Medicare Advantage plan members, essentially scamming CMS out of larger payments to cover the cost of care for beneficiaries diagnosed through the insurer’s medical assessment program.

Last year the Office of Inspector General undertook a study because it suspected Medicare Advantage Organizations (MAOs) could be using chart reviews to increase risk adjusted payments inappropriately. Unsupported risk adjusted payments are a major driver of improper payments in the Medicare Advantage (MA) program, which provided coverage to 20 million beneficiaries in 2018 at a cost of $210 billion. Arizona MA enrollment reached 574,475 in 2020.

A recently unsealed whistleblower case filed by the Department of Justice (DOJ) accuses Cigna of fraudulently over-billing for its Medicare Advantage plans. Allegations claim the company submitted unsupported diagnoses that resulted in billions in overpayments.

According to the lawsuit, Cigna used a medical assessment it called “360” to find health conditions that could raise risk scores of plan members, offering incentives to physicians who complete the assessments and using third-party contract providers to perform the health assessments in plan member homes. Cigna offered primary care doctors who performed a certain volume of 360 exams a $150 bonus per completed exam, and those who attended 360 training seminars were paid $1,000, the lawsuit alleges.

The DOJ alleges CMS overpaid Cigna an estimated $1.4 billion from 2012 to 2017 and is seeking equal to three times that amount in damages, along with a civil penalty of $11,000 for each violation. This is not the first time an MA organization has been accused of inflating plan member’s health conditions to boost the payments they received from CMS, according to HealthCareDive.

In March, Anthem was also sued by the DOJ for nearly the same thing, alleging it received millions in improper payments from CMS for failing to correct inaccurate diagnosis codes. In recent years United Health scuffled several times with the Justice Department over MA payments.

Cigna wrote in an emailed statement,

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 all unjustified allegations.

Looking at 2016 encounter data, the OIG found that Medicare Advantage Organizations almost always used chart reviews to add a diagnosis, and when reported only on chart reviews (without any service records), diagnoses resulted in roughly $6.7 billion in risk-adjusted payments for 2017, according to MedCityNews. Of that, an estimated $2.7 billion in payments were based on diagnoses that did not link to a specific service provided to the member.

Read the full report from Office of Inspector General

Read the full article from HealthCareDive

Read the full article from MedCityNews