'False and invalid diagnoses': DOJ sues Cigna for alleged Medicare Advantage fraud

Cigna is being sued by the Justice Department for allegedly making its Medicare Advantage members appear sicker than they were by submitting false diagnosis codes to the government in order to receive higher reimbursement rates.

The Oct. 17 lawsuit comes after The New York Times reported Oct. 8 that federal audits show that eight of the 10 largest Medicare Advantage insurers have submitted inflated bills. Four of the five largest MA insurers — UnitedHealth, Humana, Elevance and Kaiser — have or are facing federal lawsuits alleging efforts to overdiagnose their customers "crossed the line into fraud."

The government's lawsuit claims that Cigna hired vendors to conduct in-home assessments of MA members, usually nurse practitioners. The vendors allegedly did not perform any testing that would have led to reported diagnoses, and Cigna did not allow any treatments to be provided for the medical conditions that were reported.

The core issue, according to the Justice Department, is that Cigna then submitted incorrect diagnoses to CMS and certified every year its submissions were "accurate, complete, and truthful."

"As alleged, Cigna obtained tens of millions of dollars in Medicare funding by submitting to the government false and invalid diagnoses for its Medicare Advantage plan members," U.S. Attorney Damian Williams said. "Cigna knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker. This office is dedicated to holding insurers accountable if they seek to manipulate the system and boost their profits by submitting false information to the government."


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