CJ Wolf
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Medicare Advantage Compliance Under the Spotlight: Lessons from Cigna's $172 Million Settlement
$172 million is a lot of money. It's also the amount that the Cigna Group recently agreed to pay to resolve allegations it violated the False Claims Act in relation to its Medicare Advantage (MA) plan enrollees. Specifically, the government alleged that Cigna submitted and failed to withdraw inaccurate and untruthful diagnosis codes in order to increase its payments from Medicare.Allegations Against Cigna Group
A whistleblower initially brought forward the allegations and the U.S. government joined the action. They claimed that, for payment years 2014 to 2019, Cigna operated a “chart review” program by obtaining medical records from healthcare providers documenting services they had previously rendered to Medicare beneficiaries enrolled in Cigna’s plans.
Cigna utilized diagnosis coders to review the records to identify all medical conditions supported in the documentation to assign diagnosis codes for those conditions. Cigna then used the results of the reviews to submit additional diagnosis codes to CMS to obtain additional payments. However, the record reviews also did not confirm some diagnosis codes that were previously reported and submitted to CMS.
According to the government’s press release, “Cigna did not delete or withdraw these inaccurate and untruthful diagnosis codes, however, which would have required Cigna to reimburse CMS. Thus, the United States alleged that Cigna used the results of its chart reviews to identify instances where Cigna could seek additional payments from CMS, while improperly failing to use those same results when they provided information about instances where Cigna was overpaid.”
Similar Enforcement Actions
Enforcement relating to MA organizations and diagnosis coding has been a significant focus over the last year or two. All indications are signaling these efforts will continue.
For example, over recent months, the U.S. Department of Health and Human Services Office of Inspector General (OIG) has added multiple work plan items focusing on these issues. These include:
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- “Audits of Medicare Part C Unlinked Chart Review Diagnosis Codes” https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000799.asp
- “Medicare Part C High-Risk Diagnosis Codes Tool Kit” https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000783.asp
- “CMS May Make Increased Payments to MA Organizations for Diagnoses That Were Reported on Physicians' Claims But Were Not Confirmed on a Concurrent Inpatient Stay” https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000788.asp
In addition, the OIG has performed audits of specific MA organizations and diagnosis coding. Examples of the most recent audit results include:
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- October 2023 – Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Aetna, Inc. Submitted to CMS https://oig.hhs.gov/oas/reports/region1/11800504.asp
- September 2023 – Medicare Advantage Compliance Audit of Diagnosis Codes That Health Net of California, Inc. Submitted to CMS https://oig.hhs.gov/oas/reports/region9/91803007.asp
- August 2023 – Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Presbyterian Health Plan, Inc. Submitted to CMS https://oig.hhs.gov/oas/reports/region7/72001197.asp
It is not just MA organizations who are subjected to risks. Providers, such as physicians participating in such plans, have seen enforcement actions as well. For example, a medical group and one of its physicians agreed to pay over $5 million to resolve allegations that they reported invalid diagnoses to MA plans and thereby caused those plans to receive inflated payments from Medicare.
In this case, multiple MA organizations in California contracted with the medical group to provide health care to patients enrolled in Medicare plans. The organizations compensated the medical group with a share of the payments they received.
Consequently, the physician group had a financial incentive to submit additional diagnosis codes in order to increase the payments the MA organizations received from Medicare. A former employed physician of the medical group brought the information to the attention of the government by alleging the medical group knowingly submitted diagnoses that were not supported in the medical records in order to inflate the payments the MA organizations received from Medicare.
Clearly, MA organizations and the diagnosis codes submitted for reimbursement are under close compliance scrutiny. Both MA organizations and providers should be diligent in their compliance efforts relating to these activities.
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