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

The Division of Justice on Tuesday submitted a lawsuit towards health and fitness insurance provider

The Division of Justice on Tuesday submitted a lawsuit towards health and fitness insurance provider Cigna alleging that the organization submitted fraudulent Medicare Advantage claims to the Facilities for Medicare and Medicaid Expert services.

The go well with claims that concerning 2012 and 2017 Cigna made use of inappropriate diagnostic codes for health and fitness conditions that its users did not have, were being not recorded in professional medical data and were being not primarily based on clinically reputable data. More than the program of that time, CMS overpaid Cigna by far more than $one.four billion, according to the DOJ.

“[Cigna] intentionally misrepresented these health and fitness conditions as section of a widespread scheme to coax CMS into paying a higher capitated charge on behalf of Medicare beneficiaries enrolled in [Cigna’s] Medicare Advantage strategies,” the DOJ said in its declare.

Cigna developed its 360 Software in 2012, in which program users would get an “improved version of an once-a-year wellness stop by” from their most important care physician. The software was said to close gaps in care and detect health and fitness conditions that were being going undetected.

“Even though [Cigna] pitched 360 in this manner, high quality of care was not the fundamental function of the 360 software,” the DOJ said. “The software centered on a business enterprise model devised by [Cigna] in which 360 would be made use of to locate health and fitness conditions that could elevate the hazard scores of the Approach Customers and hence raise the every month capitated payments that CMS paid to [Cigna].”

The lawsuit also alleges that Cigna sought out suppliers that were being unfamiliar with patients’ health and fitness history to take part in the 360 software. When participating suppliers performed a selected quantity of 360 visits, they acquired a $one hundred fifty reward for each stop by and were being paid $one,000 each individual time they attended a 360 education seminar, the DOJ said.

The department is looking for an amount of money equal to three periods the amount of money of the $one.four billion in damages as properly as a civil penalty of $eleven,000 for each individual violation.

WHY THIS Issues

Less than Medicare Advantage, CMS pays health and fitness insurers a every month capitated charge primarily based on a beneficiary’s hazard rating, which is determined primarily based on the member’s relative health and fitness standing.

In this hazard adjustment model, insurers acquired better compensation for program users that have serious and expensive health and fitness conditions.

Cigna has said that it will defend alone towards unjustified allegations.

THE Larger sized Craze

Previously this year, the DOJ hit Anthem with a comparable lawsuit involving fraudulent Medicare Advantage hazard scores.

The case accused Anthem of a one-sided evaluate of a beneficiary’s professional medical chart to locate additional codes to submit to CMS to acquire earnings, without having also determining and deleting inaccurate diagnostic codes. This created $100 million or far more a year in additional earnings for Anthem, the DOJ said.

ON THE Document

“We are happy of our industry-main Medicare Advantage software and the manner in which we carry out our business enterprise. We will vigorously defend Cigna towards all unjustified allegations,” Cigna advised Healthcare Finance News.

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