Cigna Agrees $172m Payment to Settle Fraud Allegations

A leading health insurer has agreed to pay over $172m to resolve charges it seriously violated the False Claims Act by submitting inaccurate diagnosis data to the US Government’s Medicare program.

Cigna owns and operates Medicare Advantage (MA) Organizations that offer MA Plans; a way for patients to obtain Medicare-covered benefits through private insurance plans.

The federal government’s Centers for Medicare and Medicaid Services (CMS) relies on medical diagnosis codes and other information submitted via these MA Organizations to ensure its reimbursement payments to private insurers are accurate.

However, between 2014 and 2019, it is alleged that Cigna operated a “chart review” program in which it identified and submitted new diagnosis codes to CMS that the healthcare providers had not originally reported for patients – in order to obtain extra payments from the government.

Read more on healthcare fraud: US Prosecutors Line Up Charges in $2.5bn Healthcare Fraud Cases

The firm was also accused of failing to withdraw historic diagnosis codes submitted by providers, which were subsequently found to be inaccurate or untruthful and which should have required Cigna to reimburse the CMS.

One example is patients that were diagnosed as morbidly obese, and therefore eligible for increased CMS payments, but who actually had a body mass index (BMI) reading of under 35, meaning they technically did not qualify.

In addition, the Justice Department (DoJ) claimed Cigna reported diagnosis codes to CMS that were based solely on forms completed by nurse practitioners and other healthcare professionals. They visited patient homes but didn’t conduct the testing or imaging needed to make accurate diagnoses, the DoJ alleged.

“For years, Cigna submitted to the government false and invalid diagnosis information for its Medicare Advantage plan members,” said Damian Williams, United States 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.”

According to the DoJ, over half of the country’s Medicare beneficiaries are enrolled in MA plans, costing the government over $450bn, which it pays to private insurers like Cigna.

Alongside the financial settlement, Cigna must enter into a five-year Corporate Integrity Agreement (CIA) with the US Department of Health and Human Services Office of Inspector General (HHS-OIG). This demands that the firm implements multiple accountability and auditing provisions, with board members required to make annual certifications about its compliance measures.