Multinational health insurance company Cigna agreed to pay more than $172 million as part of a settlement with the Department of Justice (DOJ) addressing allegations it submitted and failed to withdraw false claims to Medicare.
Cigna submitted inaccurate or untruthful diagnosis codes related to various risk factors like obesity, the DOJ announced in a press release Saturday. The company reported diagnosis codes based on forms completed by vendors retained and paid by Cigna to conduct in-home assessments, the agency said. In some cases, in-home healthcare providers could not reliably diagnose patients and were prohibited from providing treatment by Cigna for medical conditions they purportedly found, the DOJ alleged.
The settlement resolved a lawsuit brought under the qui tam provisions of the False Claims Act by Robert Cutler, a former part-owner of a vendor retained by Cigna to conduct home visits. He will receive more than $8.1 million.
The details: Between 2014 and 2019, Cigna’s chart review program submitted diagnosis codes to Medicare that healthcare providers had not reported to obtain additional payments, the DOJ alleged.
Between 2016 and 2021, Cigna improperly diagnosed patients as morbidly obese when their body mass index did not meet the requirements for diagnosis, the DOJ alleged. Cigna allegedly submitted and failed to delete or withdraw the inaccurate diagnosis codes to increase the payments it received.
Compliance considerations: Cigna agreed to a five-year corporate integrity agreement with the Department of Health and Human Services Office of Inspector General. The settlement requires certain undertakings, including:
- Implementing accountability and auditing provisions;
- On an annual basis, certifying compliance measures with top executives and the board;
- Conducting annual risk assessments and other monitoring; and
- Conducting independent audits focused on risk adjustment data.
Company response: In a press release, Cigna touted a recent successful program audit by the Centers for Medicare and Medicaid Services.
“We hold ourselves to high standards for serving Medicare beneficiaries and all of our customers and are constantly evaluating and evolving our processes accordingly,” said Chris DeRosa, president of Cigna Healthcare’s U.S. government business, in the release. “This resolution provides us another important tool to gain insights and further improve our support for beneficiaries, and we look forward to continuing our collaborative and constructive relationship with the government.”