The Justice Department is intervening in a whistleblower lawsuit, first filed in 2017.
Medicare Advantage (MA) plans have long been accused of upcoding, defined as "systematically assessing enrollees as having more health conditions and being sicker on average than is actually the case." Upcoding results in more patients assessed as higher risk, which draws higher payments from Medicare.
The Department of Justice (DOJ) has now made these claims against Cigna, filing a civil fraud lawsuit on October 17 and joining an existing whistleblower suit first filed in 2017.
In a statement for the suit, the DOJ writes: "The lawsuit seeks damages and penalties under the False Claims Act for CIGNA's submissions to the Government of false and invalid patient diagnosis codes to artificially inflate the payments CIGNA received for providing insurance coverage to its Medicare Advantage plan members."
The 360 assessment
At the center of the suit is the in-home version of Cigna's "360 comprehensive assessment program," an annual member assessment completed by contracted Vendor Health Care Providers (Vendor HCPs)—generally nurse practitioners and, according to the suit, "on occasion by other nonphysician healthcare providers such as registered nurses and physician assistants."
The suit details that the Vendor HCPs would use a "360 form" with a multi-page checklist to document medical conditions that could not be corroborated by other provider documentation during the same year. In addition, the suit alleges, the Vendor HCPs completing the forms "did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found."
The dollar details
In the DOJ's statement regarding the suit, U.S. Attorney Damian Williams said: "As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members.
The full DOJ suit states that "Cigna carefully tracked the return on investment ('ROI') from the 360 home visits by comparing the total amounts paid to vendors to perform the in-home visits to the additional PMPM payments generated by the resulting increased risk scores for Plan members."
Two examples cited include a projected profit of $61.8 million on 2014 home visits costing $18.8 million and a $38.8 million projected profit versus an $8.7 million spend for the first eight months of 2015.
The suit continues: "Tellingly, the ROI calculations included as a cost only the payments to vendors for conducting home visits—but did not incorporate any additional costs for actually treating the additional medical conditions that the Vendor HCPs had purportedly diagnosed."
The DOJ detailed seven specific instances among the "tens of thousands of false and invalid diagnosis codes" included in the suit.
The DOJ's complete filing can be found here.
Laura Beerman is a contributing writer for HealthLeaders.
KEY TAKEAWAYS
The Department of Justice has filed a civil fraud lawsuit against Cigna for Medicare Advantage overpayments.
The suit alleges that Vendor Health Care Providers documented medical conditions during in-home MA member assessments that were not supported by the ordering of diagnostic services or by other provider documentation.
The result was the submission of "tens of thousands of false and invalid diagnosis codes" that helped Cigna obtain "tens of millions of dollars" in fraudulent payments from Medicare.