DOJ: Cigna will pay $172 million to settle claims about false data in Medicare Advantage plans

Edmund H. Mahony, Hartford Courant on

Published in Business News

Cigna agreed Saturday to pay slightly more than $172 million to settle a claim by the government that it submitted false health data to Medicare in order to increase payments it received for patients enrolled in its Medicare Advantage programs, the justice department said.

Cigna owns and operates businesses that offer Medicare Advantage plans across the country.

The federal government claimed that the company submitted “inaccurate and untruthful” patient diagnosis data to Medicare in order to inflate the payments it received, that it failed to withdraw the inaccurate diagnosis data and repay Medicare, and falsely certified in writing that the data was truthful.

“Over half of our nation’s Medicare beneficiaries are now enrolled in Medicare Advantage plans, and the government pays private insurers over $450 billion each year to provide for their care,” Deputy Assistant Attorney General Michael D. Granston said when announcing the settlement. “We will hold accountable those insurers who knowingly seek inflated Medicare payments by manipulating beneficiary diagnoses or any other applicable requirements.”

Under the government Medicare Advantage Program, also known as Medicare Part C, beneficiaries can obtain their Medicare-covered benefits through private insurance plans known as Medicare Advantage plans.

Medicare pays the advantage plans a fixed monthly amount for each beneficiary who enrolls. It adjusts the payments so that plan operators are paid more for high risk patients with anticipated higher health care costs and less for those believed to be in better health.

Medicare sets its risk adjustments in part on diagnostic codes provided by operators of advantage plans, like Cigna.

The government claimed that from 2014 to 2019, Cigna added data to medical records obtained from physicians in order to increase its payments from Medicare. At the same time, the government charged that Cigna did not delete or correct inaccurate diagnostic codes that would have required it to reimburse Medicare.


“Thus, the United States alleged that Cigna used the results of its chart reviews to identify instances where Cigna could seek additional payments from (Medicare), while improperly failing to use those same results when they provided information about instances where Cigna was overpaid,” the government said in a statement outlining the settlement.

Cigna officials could not be reached immediately.

The government also claimed that Cigna reported diagnosis codes to Medicare based on incomplete examinations.

“The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the diagnostic testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported, and were in many cases prohibited by Cigna from providing any treatment during the home visits for the medical conditions they purportedly found,” the government statement said.

In addition, the government said Cigna over reported morbid obesity among its plan beneficiaries in order to increase its payments from Medicare.

As part of the settlement, the government said Cigna agreed to a five-year compliance plan with the Department of Health and Human Services that requires top executives and board members to certify corporate compliance measures, among other measures.

The justice department disclosed that, under federal whistleblower law, a former part owner of a Cigna vendor involved in the home visit portion of the settlement, will receive $8.1 million from the settlement.

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