Connecticut-based healthcare giant, Cigna Group, has agreed to pay a hefty $172,294,350 settlement to resolve allegations of violating the False Claims Act. The company was accused of submitting inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan enrollees. These codes were allegedly manipulated to increase payments from Medicare, a program that provides healthcare coverage to millions of Americans.
Medicare Advantage, also known as Medicare Part C, allows beneficiaries to receive Medicare-covered benefits through private insurance plans. The Centers for Medicare and Medicaid Services (CMS) pays these plans based on various factors, including medical diagnosis codes, which help determine the expected health expenditures for beneficiaries.
The allegations against Cigna spanned from 2014 to 2019 and included claims that the company operated a program to review medical records and identify conditions that were not previously reported. Cigna then used these findings to submit additional diagnosis codes to CMS, inflating payments without proper validation. Additionally, Cigna was accused of reporting diagnosis codes based solely on forms completed by vendors, without adequate medical testing or imaging.
In response to the settlement, Cigna has entered into a five-year Corporate Integrity Agreement with the U.S. Department of Health and Human Services Office of Inspector General. This agreement mandates rigorous accountability measures, including annual certifications, risk assessments, and independent audits focused on risk adjustment data.
The case, brought under the False Claims Act's whistleblower provisions, was resolved through a joint effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the United States Attorneys’ Offices for the Eastern District of Pennsylvania, the Southern District of New York, and the Middle District of Tennessee, with support from the HHS-OIG. As part of the settlement, the whistleblower, Robert A. Cutler, will receive $8,140,000 for his role in bringing the false claims to light.
This settlement underscores the government's commitment to combat healthcare fraud and maintain the integrity of federal healthcare funds, especially within vital programs like Medicare Advantage.
Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at www.oig.hhs.gov/fraud/report-fraud/ or 800-HHS-TIPS (800-447-8477).
