Cigna Group To Pay More Than $172 Mln To Settle Medicare Over-payment Claims

(RTTNews) - Cigna Group agreed to pay about $172.29 million to resolve allegations that it violated the False Claims Act by submitting and failing to withdraw inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan enrollees in order to increase its payments from Medicare.

Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries have the option of obtaining their Medicare-covered benefits through private insurance plans called MA Plans. The Centers for Medicare and Medicaid Services (CMS) pays the MA Plans a fixed monthly amount for each beneficiary who enrolls.

CMS adjusts these monthly payments to account for various "risk" factors that affect expected health expenditures for the beneficiary, to ensure that MA Plans are paid more for those beneficiaries expected to incur higher healthcare costs and less for healthier beneficiaries expected to incur lower costs. To make these adjustments, CMS collects "risk adjustment" data, including medical diagnosis codes, from the MA Plans.

The United States alleged that, for payment years 2014 to 2019, Cigna operated a "chart review" program, pursuant to which it retrieved medical records from healthcare providers documenting services they had previously rendered to Medicare beneficiaries enrolled in Cigna's plans.

Cigna retained diagnosis coders to review those charts to identify all medical conditions that the charts supported and to assign the beneficiaries diagnosis codes for those conditions. Cigna relied on the results of those chart reviews to submit additional diagnosis codes to CMS that the healthcare providers had not reported for the beneficiaries to obtain additional payments from CMS.

However, Cigna's chart reviews also did not substantiate some diagnosis codes that were reported by providers and previously submitted by Cigna to CMS. Cigna did not delete or withdraw these inaccurate and untruthful diagnosis codes, however, which would have required Cigna to reimburse CMS, the U.S. Department of Justice said in a statement.

As part of the resolution, Cigna Group will also enter into a Corporate Integrity Agreement with the Office of Inspector General of the U.S. Department of Health and Human Services. The agreement is designed to promote ongoing compliance with federal health program requirements over a period of 5 years.