Insurer Cigna Group has agreed to pay $37 million to settle charges its actions artificially inflated its Medicare Advantage payments.
The U.S. government had charged Cigna with submitting false or invalid patient diagnosis codes “in tens of thousands of instances” to artificially inflate its payments from the program.
Cigna’s vendors, typically nurse practitioners, did in-home assessments at the patients’ homes. They completed forms with diagnosis codes but didn’t perform the testing or imaging needed to reliably diagnose the serious conditions they say they found, said a statement released Sept. 30 by the U.S. Attorney’s Office for the Southern District of New York.
The health conditions identified were not reported by any other health provider who saw the patient during the year in their homes, it added.
“For years, Cigna submitted to the government false and invalid diagnosis information for its Medicare Advantage plan members,” said Damian Williams, the U.S. Attorney for the Southern District of New York. “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.”
The civil lawsuit was originally filed by a whistleblower in the U.S. District Court for the Southern District of New York and later transferred to the Middle District of Tennessee.
“Medicare Advantage relies on the integrity of its insurers and the accuracy of the diagnosis code information they provide since it has an outsize effect on Medicare payments. We will continue to vigorously pursue fraud in this increasingly important program,” said Henry C. Leventis, U.S. Attorney for the Middle District of Tennessee.