June 21, 2024


The business lovers

DOJ brings lawsuit against Cigna for allegedly submitting $1.4 billion in false Medicare Advantage claims

The Division of Justice on Tuesday filed a lawsuit in opposition to well being insurer Cigna alleging that the enterprise submitted fraudulent Medicare Benefit promises to the Facilities for Medicare and Medicaid Expert services.

The fit promises that among 2012 and 2017 Cigna utilised improper diagnostic codes for well being ailments that its members did not have, ended up not recorded in professional medical records and ended up not primarily based on clinically reputable info. In excess of the study course of that time, CMS overpaid Cigna by far more than $one.four billion, in accordance to the DOJ.

“[Cigna] deliberately misrepresented these well being ailments as section of a common scheme to coax CMS into shelling out a larger capitated charge on behalf of Medicare beneficiaries enrolled in [Cigna’s] Medicare Benefit plans,” the DOJ stated in its declare.

Cigna designed its 360 Application in 2012, in which program members would get an “improved version of an annual wellness visit” from their primary treatment medical doctor. The application was stated to shut gaps in treatment and detect well being ailments that ended up going undetected.

“Even nevertheless [Cigna] pitched 360 in this fashion, good quality of treatment was not the underlying goal of the 360 application,” the DOJ stated. “The application centered on a business enterprise model devised by [Cigna] in which 360 would be utilised to find well being ailments that could raise the possibility scores of the Strategy Customers and therefore enhance the month-to-month capitated payments that CMS paid out to [Cigna].”

The lawsuit also alleges that Cigna sought out suppliers that ended up unfamiliar with patients’ well being record to participate in the 360 application. When taking part suppliers conducted a specified volume of 360 visits, they obtained a $150 reward for each visit and ended up paid out $one,000 every single time they attended a 360 schooling seminar, the DOJ stated.

The office is trying to find an volume equivalent to 3 situations the volume of the $one.four billion in damages as effectively as a civil penalty of $eleven,000 for every single violation.


Under Medicare Benefit, CMS pays well being insurers a month-to-month capitated charge primarily based on a beneficiary’s possibility score, which is established primarily based on the member’s relative well being status.

In this possibility adjustment model, insurers obtained greater payment for program members that have critical and pricey well being ailments.

Cigna has stated that it will protect itself in opposition to unjustified allegations.

THE More substantial Craze

Before this yr, the DOJ hit Anthem with a similar lawsuit involving fraudulent Medicare Benefit possibility scores.

The circumstance accused Anthem of a 1-sided evaluation of a beneficiary’s professional medical chart to find more codes to submit to CMS to achieve profits, with out also figuring out and deleting inaccurate diagnostic codes. This generated $a hundred million or far more a yr in more profits for Anthem, the DOJ stated.

ON THE History

“We are happy of our industry-main Medicare Benefit application and the fashion in which we conduct our business enterprise. We will vigorously protect Cigna in opposition to all unjustified allegations,” Cigna told Healthcare Finance News.

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