In a landmark settlement highlighting the critical importance of accurate healthcare billing, The Cigna Group, a Connecticut-based health insurance giant, has agreed to pay a staggering $172,294,350. This resolution comes in response to allegations of False Claims Act violations, specifically concerning the submission of inaccurate and untruthful Cigna Diagnosis Codes 2023 and prior years for its Medicare Advantage Plan enrollees. These actions were alleged to have artificially inflated payments received from Medicare.
The case sheds light on the complexities of the Medicare Advantage (MA) Program, also known as Medicare Part C, where beneficiaries can opt for private insurance plans to manage their Medicare benefits. The Centers for Medicare and Medicaid Services (CMS) compensates MA Plans with a fixed monthly sum per enrollee. Crucially, these payments are adjusted based on “risk factors,” including medical diagnosis codes, to ensure higher payments for sicker individuals and lower payments for healthier ones. This risk adjustment mechanism relies heavily on the accuracy of diagnosis codes submitted by MA Plans.
Cigna, a major player in the MA landscape, faced accusations of exploiting this system. The core allegation was that Cigna knowingly submitted false patient diagnosis data – specifically inaccurate cigna diagnosis codes 2023 and earlier – to CMS. This was reportedly done to boost their Medicare payments. Furthermore, Cigna allegedly failed to withdraw these incorrect codes and repay the overpayments, compounding the issue. The settlement directly addresses these accusations, bringing to a close a significant chapter in healthcare fraud enforcement.
“With over half of the nation’s Medicare beneficiaries enrolled in Medicare Advantage plans, and the government allocating over $450 billion annually for their care, the integrity of this system is paramount,” stated Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division. “We are committed to holding accountable insurers who deliberately seek inflated Medicare payments through manipulation of beneficiary diagnoses or other fraudulent practices. This case involving cigna diagnosis codes 2023 serves as a clear warning.”
The government’s investigation revealed that from 2014 to 2019, Cigna employed a “chart review” program. This involved retrieving medical records from healthcare providers and tasking diagnosis coders to identify and assign diagnosis codes for all conditions supported by these records. While this process aimed to capture comprehensive patient health information, it was allegedly misused. Cigna selectively used these chart reviews to submit additional diagnosis codes to CMS, codes that weren’t initially reported by the providers, to increase payments. However, when these reviews uncovered unsubstantiated diagnosis codes that had already been submitted, Cigna allegedly failed to remove them and return the overpayments. This selective approach, prioritizing payment increases while ignoring overpayment corrections related to cigna diagnosis codes 2023 and earlier, formed a key part of the fraudulent scheme.
U.S. Attorney Jacqueline C. Romero of the Eastern District of Pennsylvania emphasized the significance of this case in the context of Medicare Advantage growth: “Investigating fraud within Medicare Part C is increasingly vital. Combatting Medicare Advantage fraud is a priority for my office. We are dedicated to holding accountable those who submit unsupported diagnoses to inflate Medicare Advantage payments, including instances involving unsupported diagnosis codes for conditions like morbid obesity and other inaccurate cigna diagnosis codes 2023.”
Further allegations detailed Cigna’s use of in-home assessments conducted by vendors. These assessments, often performed by nurse practitioners, were intended to evaluate plan members’ health. However, the government alleged that diagnoses, particularly for serious and complex conditions, were reported to CMS based solely on forms from these home visits. Crucially, these providers often did not conduct the necessary diagnostic testing to support such complex diagnoses and were even restricted from providing treatment during these visits. Despite the lack of robust clinical support and the absence of corroborating diagnoses from regular healthcare providers, Cigna allegedly submitted these diagnoses, including potentially inaccurate cigna diagnosis codes 2023, to claim higher payments. Each year, Cigna falsely certified the accuracy and truthfulness of this diagnosis data submitted to CMS.
Damian Williams, United States Attorney for the Southern District of New York, condemned Cigna’s actions: “For years, Cigna knowingly submitted false and invalid diagnosis information for its Medicare Advantage plan members. These reported diagnoses of serious conditions were based on superficial in-home assessments, lacking necessary diagnostic rigor. Cigna was aware that these diagnoses would artificially inflate their Medicare Advantage payments by portraying their plan members as sicker. Our Office is committed to holding insurers accountable when they manipulate the Medicare Advantage Program and boost profits by submitting false information, including misrepresenting cigna diagnosis codes 2023, to the Government.”
United States Attorney for the Middle District of Tennessee, Henry C. Leventis, highlighted the reliance on insurer integrity within Medicare Advantage: “Medicare Advantage depends on the honesty of its insurers and the accuracy of the diagnosis code information they provide, as this information significantly impacts Medicare payments. We will aggressively pursue fraud in this increasingly crucial program, especially when it involves the deliberate misuse of diagnosis codes like cigna diagnosis codes 2023 for financial gain.”
The allegations also specifically targeted the submission of inaccurate cigna diagnosis codes 2023 and prior for morbid obesity from 2016 to 2021. Diagnosing morbid obesity typically requires Body Mass Index (BMI) recordings. The government alleged Cigna submitted or failed to remove morbid obesity diagnosis codes for individuals without a BMI of 35 or higher, directly inflating payments.
In conjunction with the settlement, Cigna has entered into a five-year Corporate Integrity Agreement (CIA) with the HHS-OIG. This CIA mandates significant accountability and auditing measures, including annual certifications from top executives and board members regarding compliance, annual risk assessments, and independent audits of risk adjustment data, particularly focusing on the accuracy of cigna diagnosis codes 2023 and future submissions.
Christian J. Schrank, Deputy Inspector General for Investigations with HHS-OIG, underscored the gravity of such actions: “Medicare Advantage plans that submit false information to increase payments from CMS demonstrate a blatant disregard for the integrity of vital federal healthcare funds. Such actions undermine the Medicare program and the millions of patients who depend on its services. We, alongside our law enforcement partners, will continue to prioritize investigating alleged fraud targeting the Medicare Advantage program and the misuse of diagnosis codes, including instances related to cigna diagnosis codes 2023.”
The whistleblower, Robert A. Cutler, a former part-owner of a Cigna vendor, will receive $8,140,000 from the settlement related to the home visit allegations under the False Claims Act qui tam provisions.
This settlement is a result of collaborative efforts between the Justice Department’s Civil Division and U.S. Attorneys’ Offices across multiple districts, with crucial assistance from HHS-OIG. This case emphasizes the government’s strong commitment to combating healthcare fraud and ensuring the integrity of Medicare Advantage. The False Claims Act remains a powerful tool in this fight, and the public is encouraged to report any potential fraud, waste, abuse, and mismanagement to the Department of Health and Human Services.
It is important to note that the claims resolved by this settlement are allegations, and there has been no determination of liability.
