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.
