Cigna to pay $172M over alleged Medicare Advantage fraud

The Cigna Group will pay $172.3 million to resolve allegations that it violated the False Claims Act by submitting incorrect Medicare Advantage patient data to CMS to receive higher payments from the agency.

The U.S. Attorney's Office for the Eastern District of Pennsylvania alleged Sept. 30 that Cigna also falsely certified that the submitted data was accurate, failed to withdraw the "untruthful" data and did not repay CMS.

For payment years 2014 to 2019, the Justice Department alleges that Cigna did not verify the accuracy of diagnosis codes reported by providers before submitting to CMS and reviewed charts to identify where it could receive additional payments from CMS.

For payment years 2016 to 2021, the government alleges Cigna purposefully submitted and failed to withdraw inaccurate codes for morbid obesity specifically. 

Cigna will use $135.3 million from the settlement to resolve the allegations from the Justice Department. The remaining $37 million will resolve allegations related to unsupported diagnoses for Medicare Advantage enrollees that received in-home services from Cigna.

As part of the settlement, Cigna has entered into a five-year accountability and auditing agreement with HHS' Office of Inspector General, which will require company executives and board members to certify Cigna's compliance moving forward. The payer must also conduct annual risk assessments and submit to independent risk adjustment audits.

"These agreements fully resolve long-running legal matters, enabling us to focus our resources on all those we serve and avoiding the uncertainty and further expense of protracted litigation," Chris DeRosa, president of Cigna Healthcare's U.S. government business, said in a Sept. 29 news release. "We are pleased to move beyond industrywide legal disputes related to past risk adjustment practices, and we look forward to continuing to provide high-quality, affordable Medicare Advantage coverage to our customers and delivering value to the taxpayers in the years ahead."

Nearly every major insurance company has previously been accused of or settled allegations of Medicare Advantage fraud by the federal government. In January, CMS issued a final rule that will implement stricter auditing standards for Medicare Advantage plans. The agency estimates it could recover $4.7 billion in overpayments to MA plans in the next decade with the new audit methodology. 

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