- Cigna falsified the health conditions of its Medicare Advantage plan members to coax CMS into making larger payments to the insurer on behalf of beneficiaries, a U.S. Justice Department lawsuit alleges. Cigna did not respond to a request for comment.
- 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 gave the exam and using third-party contract providers to perform them in plan member homes, according to the lawsuit.
- CMS overpaid Cigna an estimated $1.4 billion from 2012 to 2017 and DOJ is seeking equal to three times that amount in damages, along with a civil penalty of $11,000 for each violation.
This isn't Cigna's first brush with the DOJ — in 2016 it was temporarily banned from selling its MA plans after CMS found it failed to abide by compliance program requirements.
It's also 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.
Anthem got hit with a DOJ lawsuit in March for nearly the same thing, alleging it received millions in improper payments from CMS for failing to correct inaccurate diagnosis codes. UnitedHealth in recent years scuffled several times with the Justice Department over MA payments.
Under Medicare Advantage, CMS pays private insurers a monthly rate based on each beneficiary's risk adjustment scores.
MA insurers submit ICD codes describing relevant health conditions for each beneficiary. CMS then assigns a numerical value — more serious and costly chronic conditions are assigned higher values than generic health issues. The values are added together to generate a risk score that represents the financial risk a patient's current health conditions could pose on the payer.
The Cigna lawsuit centers around its 360 health assessment program, which it used to assess beneficiary conditions and ultimately risk adjustment scores through a form completed by primary care doctors.
The form didn't require providers to state whether the information reported was derived anecdotally from a patient or was clinically proven, resulting in "improper diagnostic codes that referred to health conditions of Medicare beneficiaries that did not exist, were not recorded in any medical records, and were not based on clinically reliable information," according to the lawsuit.
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.
It also used six contract providers to perform the 360 exams at beneficiary homes nationwide from 2012 to 2017.
Cigna-affiliate Alegis and THM were the two largest contract providers, accounting for about 60% of all the 360 exams performed by Cigna each year, according to the lawsuit.