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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.