Cigna will pay $172M for allegedly filing false claims that lacked necessary imaging to back diagnosis codes

Cigna has agreed to pay $172,294,350 to settle allegations that it violated the False Claims Act, including submitting diagnosis codes unsupported by necessary medical imaging, authorities announced Saturday.

Under the Medicare Advantage program, the Bloomfield, Connecticut-based insurer would purportedly base such diagnoses on in-home patient assessments of beneficiaries typically conducted by nurse practitioners. These NPs would often diagnose serious, complex conditions without the necessary medical imaging or diagnostic tests to reach such conclusions, the Department of Justice said.

Other healthcare providers who saw these patients did not report such diagnoses to Cigna during the year in which the home visits occurred.

“For years, Cigna submitted to the government false and invalid diagnosis information for its Medicare Advantage plan members,” Damian Williams, U.S. Attorney for the Southern District of New York, said in a Sept. 30 announcement from the DOJ. “The reported diagnoses of serious and complex conditions were based solely on cursory in-home assessments by providers who did not perform necessary diagnostic testing and imaging. Cigna knew that these diagnoses would increase its Medicare Advantage payments by making its plan members appear sicker.”

Cigna owns and operates organizations that offer Medicare Advantage plans to beneficiaries across the country. Authorities allege that the insurer submitted “inaccurate and untruthful” diagnosis data to inflate payments received from CMS. The company also purportedly failed to withdraw this data and repay CMS, and it falsely certified in writing that the data was accurate. The DOJ further alleged that between 2014 to 2019, Cigna ran a “chart review program” that did not properly substantiate diagnosis codes submitted to CMS.

Along with paying the settlement, Cigna is entering into a five-year corporate integrity agreement with the HHS Office of Inspector General. Under the pact, Cigna must implement “numerous” accountability and auditing provisions, including requiring top execs and board members to certify that Cigna is following the proper compliance measures. The insurer also must perform annual risk assessments and other monitoring, with an independent reviewer conducting regular audits.

The civil settlement of the home visit-related allegations comes after a whistleblower filed suit under the False Claims Act last year, with the feds later joining the complaint. Robert A. Cutler—former part-owner of a vendor retained by Cigna to conduct the home visits—stands to receive $8.14 million from the settlement under provisions of the FCA.

“Invalid” diagnoses listed in the original complaint included (but were not limited to) congestive heart failure, chronic kidney disease, diabetes with renal complications, and rheumatoid arthritis. Diagnosing the latter requires multiple blood tests, X-rays or both, according to the American College of Rheumatology. However, Cigna’s vendor administered neither but submitted “thousands” of rheumatoid arthritis diagnoses based on home visits cited in its risk-adjustment submissions to CMS.

The claims are only allegations, and there has been no determination of liability, the DOJ emphasized.

Cigna issued a separate statement Sept. 29, noting that it recently completed a successful program audit conducted by CMS “with strong results.”

“We hold ourselves to high standards for serving Medicare beneficiaries and all of our customers, and we are constantly evaluating and evolving our processes accordingly,” Chris DeRosa, president of Cigna Healthcare's U.S. government business, said in the statement. “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.”