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This is the case of U.S. v. Cigna Corp. et al., in the U.S. District Court for the Middle District of Tennessee.

On Monday, The U.S. federal government intervened in a civil lawsuit alleging that Cigna Corp. overbilled its Medicare Advantage payments. The complaint alleges that Cigna submitted overstated diagnoses for patients to make it seem as though they had more serious medical conditions.

The Government is intervening in a lawsuit filed 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 Middle District of Tennessee.

According to the complaint, from 2012 to 2019, Cigna is alleged to have submitted fake or exaggerated patient diagnosis reports to the government to “improperly inflate” the payments that Cigna received for providing services to patients covered under Medicare Advantage policies.

On Monday, U.S. Attorney Damian Williams said in a statement that “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.”

The government claims that “Cigna knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker.” The government contends that Cigna knowingly submitted diagnosis codes for serious and chronic medical conditions based on home visits by health care professionals who failed to actually perform any testing to reliably provide such a diagnosis with those types of complex conditions being reported.

The complaint further alleges that Cigna prohibited its health care providers from providing any treatment during the home visit for the medical conditions they supposedly discovered. The government also pointed out that none of the Patients’ other physicians who treated them at other times, ever reported the ailments that Cigna allegedly found.

The government is represented by Damian Williams and Peter Aronoff of the U.S. Attorney’s Office for the Southern District of New York and Mark H. Wildasin and Kara F. Sweet of the U.S. Attorney’s Office for the Middle District of Tennessee.

Attorneys for the government said that Cigna submitted fake, yet serious diagnoses so that it could claim larger reimbursements from Medicare. It also alleges that the insurer knowingly submitted false certifications every year, claiming that its diagnosis submissions were “accurate, complete, and truthful.”

Whistleblower and complainant, Robert A. Cutler, an employee of Cigna contractor Texas Health Management LLC, filed a False Claims Act in 2017, but the case remained under seal until it was made public in August 2020.

The government’s complaint comes two years later. In the complaint, Cutler detailed one instance of billing codes that were being added for chronic obstructive pulmonary disease and dementia, even though a nurse reported that the patients had no such conditions.

Cutler also claimed that Cigna trained its contractors to make fake diagnoses for rheumatoid arthritis based only on weight loss, fatigue, or symptoms of stiffness or pain. The complaint says that the government was “unaware that these claims were false and fraudulent,” and it “overpaid Cigna by more than $1.4 billion.”

The lawsuit filed by Cutler was originally filed in New York federal court, but Cigna contested jurisdiction and the case was ultimately transferred to Tennessee, against Cutler’s objections.

In August, Judge Eli Richardson of the U.S. District Court granted the government’s motion to intervene in Cutler's suit, but not before rebuking Cigna’s lawyers for their description of the anti-fraud statute’s good-cause standard arguing the government's late intervention in whistleblower complaints.

In the government's intervening complaint filed on Monday, the government claims that Cigna’s vendors visited patients at their homes and filled out a form created by Cigna that included a “check-the-box” list of a wide range of various medical conditions to select from.

The government’s complaint alleges that Cigna would then have its coding teams identify diagnosis codes that corresponded to the reported medical conditions before they submitted them for reimbursement from the Centers for Medicare and Medicaid Services.

The complaint states that Cigna used those home visits to illicit lucrative diagnosis codes that would drastically raise its monthly reimbursements from Medicare and Medicaid Services, without providing any actual medical care, and that it deceptively did not inform its policyholders of its nefarious activities.

The complaint also alleges that Cigna and its vendors specifically targeted plan members to visit at home, who it believed had the greatest risk score increases so that it could maximize the greatest increased reimbursements.

The government said that these fake diagnoses included congestive heart failure, rheumatoid arthritis, diabetes, and chronic kidney disease. The government said that Cigna pressured its vendor health care providers to record “high-value diagnoses” and closely tracked the diagnoses recorded by each vendor’s home visits.

According to the government, Cigna submitted fake diagnosis codes for tens of thousands of invalid diagnoses to Medicare and Medicaid, which resulted in the insurer receiving tens of millions of dollars in risk adjustment payments from the Centers for Medicare and Medicaid Services.

The Office of Inspector General has flagged home assessments such as those conducted by Cigna and its vendors, alleging that these visits can potentially be the source of overpayment, and estimated that Medicare paid out $2.6 billion in 2017 alone, for diagnoses that were related only to these home visits.