Damian Williams, the United States Attorney for the Southern District of New York, announced that the United States has filed a civil health care fraud complaint against CIGNA CORPORATION and its subsidiary Medicare Advantage Organizations (collectively, ” CIGNA”). Lawsuit seeks damages and penalties under the False Claims Act for CIGNA’s submissions to the government of false and invalid patient diagnosis codes to artificially inflate payments CIGNA received for providing insurance coverage to its Medicare Advantage plan members. The government is intervening in a lawsuit brought by a whistleblower, which was originally filed in the United States District Court for the Southern District of New York and later transferred to the Intermediate District of Tennessee.
The government’s complaint alleges that the reported diagnostic codes were based solely on forms completed by providers retained and paid by CIGNA to perform in-home assessments of plan members. The health care providers (usually nurse practitioners) who made these home visits did not perform or order the tests or imaging that would have been necessary to reliably diagnose the serious and complex conditions reported and been prohibited by CIGNA from providing treatment during the home visit for medical conditions they allegedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor and were not reported to CIGNA by any other health care provider who saw the patient during the year in which the home visit took place. Nevertheless, CIGNA submitted these diagnoses to the government to demand increased payments and falsely certified each year that its diagnostic data was “accurate, complete and true”.
US Attorney Damian Williams said, “As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting false and invalid diagnoses to the government for members of its Medicare Advantage plan. CIGNA knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members seemed sicker. This office is dedicated to holding insurers accountable if they seek to manipulate the system and increase their profits by submitting false information to the government.
Medicare Advantage, also known as the Medicare Part C program, provides health insurance coverage to tens of millions of Americans opting out of traditional health insurance. Under Medicare Part C, Medicare Advantage Organizations (“MAOs”), typically operated by private insurers such as CIGNA, provide coverage to Medicare beneficiaries. In return, MAOs receive capitation payments from the Centers for Medicare and Medicaid Services (“CMS”) based on the demographic information and diagnoses of each plan beneficiary. MAOs submit diagnostic data, usually provided by beneficiaries’ healthcare providers, to the CMS. CMS then uses this diagnostic data, in conjunction with demographic factors, to calculate a “risk score” for each beneficiary and, in turn, the amount of monthly capitation payment MAO will receive to cover that beneficiary. The Medicare Advantage payment model aims to pay MAOs more to provide health care to sicker enrollees (which are expected to incur higher healthcare costs) and less for healthier enrollees (which are expected to incur lower costs ).
The following allegations are based on the complaint that was filed in federal court:
CIGNA, through its subsidiaries and affiliates, owns and operates many MAOs that administer Medicare Advantage plans. CIGNA has contracted with several providers to conduct home visits to Medicare Advantage plan members across the country as part of its broader so-called “360 Comprehensive Assessment” program. Home visits were generally conducted by nurse practitioners and occasionally by other non-physician health care providers, such as registered nurses and physician assistants (“health care providers”). Based on the visit, the providers’ healthcare professionals completed a CIGNA-created form (“Form 360”) that included a multi-page checklist containing a wide range of medical conditions. CIGNA instructed its coding teams to identify diagnostic codes that matched medical conditions on record and then submit them to CMS for risk adjustment payment.
CIGNA structured the 360 home visits with the primary purpose of capturing and recording lucrative diagnostic codes that would significantly increase the monthly per capita payments received from CMS. The purpose of the visits was not to treat the patients’ medical conditions, and CIGNA explicitly prohibited the provider’s healthcare professionals from providing any actual treatment or care to the patients. As CIGNA acknowledged in an internal document discussing the program, “[t]he primary purpose of a 360° visit is administrative code entry and not chronic care or acute care management.” But this was not disclosed to CIGNA plan members during the scheduling of the home visit or during the visit itself. When identifying plan members to receive home visits, CIGNA targeted individuals who were likely to generate the largest increases in risk score and therefore the largest payout increase.
Vendor’s healthcare professionals spent limited time with patients and did not perform a full physical examination. When performing assessments and recording diagnoses, the provider’s healthcare professionals relied heavily on patient self-assessment and their answers to various basic screening questions. Health care providers did not have access to the patient’s complete medical history and generally did not obtain or review relevant records from the patient’s primary care physician prior to the visit.
CIGNA’s 360 Home Visiting Program has consistently generated false and invalid diagnostic codes for certain serious and complex conditions that cannot be reliably diagnosed at home and without extensive diagnostic testing or imaging. In tens of thousands of cases, CIGNA has submitted diagnostic codes that represent serious and complex medical conditions that (a) were based solely on home visits made by provider healthcare professionals; (b) required specific tests or imaging to be reliably diagnosed, which was not performed; (c) was not supported by the information documented on the Form 360 completed by the provider’s healthcare professionals; and (d) have not been reported by any other health care provider who saw the Plan Member during the year in which the home visit occurred (the “Invalid Diagnoses”). Invalid diagnoses included, but were not limited to, diagnoses of complex medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with kidney complications. According to CIGNA’s own clinical guidelines, accurate diagnosis of these conditions requires specialized testing.
CIGNA pressured provider health care providers to record high-value diagnoses that dramatically increased risk adjustment payments. CIGNA management identified at least twelve classes of generic chronic diagnoses that they believed were “often underdiagnosed” among its plan members and, through training and seminars, encouraged health care providers to make these diagnoses during home visits. CIGNA also closely tracked the volume and nature of diagnoses generated by each provider’s home visits, as well as how diagnoses affected risk-adjusted payouts. CIGNA provided training to vendors to improve their “performance” when they failed to deliver the expected level of high-value diagnostic codes.
Indeed, CIGNA tracked the ROI of the 360 Home Visiting Program by comparing the costs of home visits (i.e. payments to providers) to the additional Part C payments generated by the increase in risk scores. For example, according to an internal report, CIGNA determined that in the first nine months of 2014, a provider’s 6,658 home visits resulted in more than $14 million in additional health insurance payments. which eclipsed the approximately $2.13 million that CIGNA paid to the seller. When it was found that specific vendors had fewer diagnostics than expected, CIGNA asked the vendor to prepare a “Performance Improvement Plan” for the vendor.
The invalid diagnoses generated by the 360 home visits also did not comply with the International Classification of Diseases (“ICD”) Bureau guidelines for coding and reporting (the “ICD Guidelines”), as required by applicable federal regulations. Invalid diagnoses did not affect the care, treatment, or management of the patient at the home visit, as required by ICD guidelines, and therefore were not eligible for the risk adjustment. Additionally, invalid diagnoses were not supported by the minimum information recorded on Forms 360, in violation of the ICD guidelines’ requirement for documentation of medical records. In fact, in some cases, Form 360s include clinical test results that contradict the supposed diagnosis. For example, a patient was diagnosed with congestive heart failure during a home visit, even though the Form 360 explicitly stated that physical exam results showed her heart to be “regular” and “normal.” and read “cardiac examination and unremarkable”.
Through its 360 home visit program, CIGNA submitted diagnosis codes to CMS for tens of thousands of invalid diagnoses that constituted false claims. Based on these unlawful misrepresentations, CIGNA improperly received tens of millions of dollars in risk adjustment payments from CMS, in violation of both the False Claims Act and the common law.
Mr. Williams thanked HHS-OIG and the U.S. Attorney’s Office for the Middle District of Tennessee for their assistance in this case.
This case is being handled by the Office’s Civil Fraud Unit. Assistant US Attorney Peter Aronoff is in charge of this case.
