The Department of Justice is suing Cigna over allegations it defrauded the Medicare program out of tens of millions of dollars by exaggerating patient illnesses to obtain increased monthly payments.
The exaggerated diagnoses were based on in-home assessment forms — not the testing or imaging required to diagnosis the complex conditions in question like kidney disease, congestive heart failure, rheumatoid arthritis and diabetes with renal complications, the DOJ alleges.
Cigna paid outside vendors to conduct in-home visits with its plan members. The insurer pressured the vendors to record high-value diagnoses that would lead to higher payments for Cigna, the department alleges.
The Medicare Advantage program pays insurers a higher monthly payment to insure members with more serious medical conditions.
Cigna knew that under Medicare Advantage “it would be paid more if its plan members appeared to be sicker,” U.S. Attorney for the Southern District of New York Damian Williams said in a statement.
The DOJ alleges that Cigna certified annually that the diagnoses were “accurate, complete, and truthful,” according to the complaint.
“We reject these allegations and will vigorously defend our Medicare Advantage business against them,” Cigna said in a email statement provided to Healthcare Dive.
The DOJ is intervening in a federal lawsuit originally filed by a whistleblower in 2017 that is now in the Middle District Court of Tennessee.
Nurse practitioners typically conducted these home visits for Cigna’s so-called 360 comprehensive assessment program. Cigna paid multiple vendors to complete the assessments with members across the country from 2012 to 2019, according to the complaint.
The purpose of the visits were not treat medical conditions but to complete the 360 form, created by Cigna, to capture diagnosis codes that would generate revenue, the DOJ alleges. These vendors were prohibited from providing any treatment during the home visits.
Nearly 6,650 home visits resulted in an extra $14 million in payments during the first nine months of 2014, the DOJ alleges, citing a internal report from Cigna. Those additional payments “far dwarfed the approximately $2.13 million that Cigna paid to the vendor,” the DOJ said in its complaint.