US Intervenes In Lawsuit Against Cigna alleging Medicare Fraud
America ı By Samuel Lopez
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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.
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