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DOJ sues Cigna alleging Medicare Advantage fraud

DOJ sues Cigna alleging Medicare Advantage fraud

The Justice Department has sued Cigna for allegedly collecting tens of millions of dollars in excess Medicare payments by exaggerating its members’ illnesses. 

The U.S. Attorney for the Southern District of New York sued Cigna on Friday in the U.S. District Court for the Middle District of Tennessee and alleges Cigna violated the False Claims Act by reporting its Medicare Advantage members were sicker than they were. The lawsuit alleges that from 2012 to 2019, Cigna hired health professionals to visit patients’ homes and falsely document medical conditions to increase the revenue it generated from taxpayers.

The Justice Department announced it planned to intervene in an ongoing whistleblower lawsuit regarding Cigna’s Medicare Advantage operations in August. Many, but not all, of the allegations in the Justice Department’s lawsuit mirror those from the whistleblower case, which was filed in 2017 in the U.S. District Court for the Southern District of New York. The whistleblower alleges that Cigna improperly billed the federal government by $1.4 billion. Federal prosecutors allege the insurer overcharged the Centers for Medicare and Medicaid Services by “tens of millions” of dollars. 

“Cigna obtained tens of millions of dollars in Medicare funding by submitting to the government false and invalid diagnoses for its Medicare Advantage plan members,” U.S. Attorney Damian Williams said in a news release. “Cigna knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker.” The government did not specify how much it is seeking in damages.

Cigna will vigorously defend its Medicare Advantage business against the allegations, a spokesperson wrote in an email. 

CMS pays health insurance companies flat fees to manage care for people enrolled in Medicare Advantage. CMS determines that fee in part based on the number and severity of medical conditions from which patients suffer. Regulators developed this methodology to dissuade insurers from cherry-picking healthy Medicare enrollees. But this policy also creates incentives for carriers to capture as many patient conditions as possible through chart reviews, home health assessments, primary care visits and other methods.

CMS spent $321 more per Medicare Advantage enrollee than it would have if the same beneficiary had been covered under fee-for-service Medicare in 2019, according to a Kaiser Family Foundation analysis. 

Cigna hired nurse practitioners to visit members’ homes for the primary purpose of capturing and recording lucrative diagnosis codes to increase payments, according to the Justice Department. Cigna prohibited these clinicians from providing patient care, the government alleges. As such, they did not perform or order the testing or imaging that would have been necessary to reliably diagnose the conditions reported, prosecutors charge. 

These clinicians diagnosed common ailments such as chronic kidney disease, congestive heart failure and rheumatoid arthritis, according to the lawsuit. Other physicians who saw those patients the same year did not report the same illnesses, the government alleges. 

Medicare Advantage carriers are under scrutiny for these practices across the board. Federal authorities also sued Elevance Health, formerly Anthem, and UnitedHealth Group for allegedly overbilling Medicare Advantage. These cases are ongoing.