Articles

Cigna Settles False Claims Allegations for Chart Review and At-Home Assessment Program for Over $172 Million

Date: November 9, 2023
Copyright 2023, American Health Law Association, Washington, DC. Reprint permission granted.

The U.S. Attorney’s Office for the Eastern District of Pennsylvania recently announced that it had reached a settlement with Cigna Group (Cigna) to resolve allegations that Cigna had violated the False Claims Act.[1] Cigna paid a total of $172,294,350 to resolve allegations related to:[2]
  1. Assigning unsupported diagnoses for Medicare Advantage (MA) beneficiaries through Cigna’s at-home risk assessment program, Cigna 360. These claims arose out of the Middle District of Tennessee and settled for $37 million.
  2. “One-way” chart reviews, where Cigna would use medical coders to review the medical records of beneficiaries enrolled in Cigna’s MA plans to add—but not remove—medical diagnostic codes. Often, the medical records did not have supporting documentation for the codes. These claims were settled for $135,294,350 with the Eastern District of Pennsylvania.
In addition to the payments to resolve both matters, Cigna agreed to enter into a five-year Corporate Integrity Agreement that includes new accountability and auditing provisions, including that Cigna executives and Board of Directors certify Cigna’s compliance measures, that Cigna conduct annual risk assessment, and that Cigna contract with an independent review organization to perform an audit focused on risk adjustment data.[3]

Background

MA Plans receive a monthly payment from the Centers for Medicare & Medicaid Services (CMS) for each beneficiary who enrolls in the plan. The payment is based on a risk-adjusted score that CMS calculates will cover the cost of the patient’s care given the patient’s current health status. The risk-adjusted score is calculated from encounter data, which includes both information health care providers submit that supports the beneficiaries’ diagnoses and health conditions, and information the MA plans submit about each beneficiary’s current health status. CMS reviews and adjusts the monthly payment amounts based on updates to encounter data and medical conditions reporting current diagnosis codes from MA plans.

Cigna 360 At-Home Risk Assessment Program

From January 2012 to December 2019, Cigna allegedly reported additional diagnostic codes based on forms used by contracted vendors to conduct at home-risk assessments of beneficiaries through nurse practitioners and other similar providers. The allegations contended that the sole purpose of these assessments was to collect diagnostic information and that the nurse practitioners were not permitted to provide treatment.[4]

Specific problematic features of the Cigna 360 program included the following:[5]
  1. Cigna tracked volume and types of diagnoses generated from home visits and the effect on risk-adjusted payments;
  2. Vendor providers were not required or allowed to conduct further evaluation for diagnoses through laboratory evaluation, diagnostic imaging, or other diagnostic testing;
  3. The identified diagnosis codes had never been reported previously by Cigna for any other encounter;
  4. Forms did not include supporting clinical information for diagnoses, including necessary diagnostic evaluation or testing; and
  5. Cigna often failed to follow-up with the patient or the patient’s primary care provider to ensure the patient received treatment for diagnoses identified in the at-home assessment.
The government alleged that Cigna’s procedures for the at-home program demonstrated that Cigna had knowledge that the diagnoses did not necessitate or change patient care treatment or management at any medical encounter for the dates of service in question.[6]

Chart Reviews

From 2014 through 2019, Cigna allegedly gathered additional information on already-rendered beneficiary services for its medical coding team to identify additional medical conditions that would require additional diagnostic codes to be submitted to CMS.[7] The government alleged that these chart reviews would systematically find retrospective additional diagnoses to support the submission of additional codes.

Allegations also included that, for payments from 2016 to 2021, the coding team was instructed to conduct “one-way” chart reviews, meaning they did not look for or adjust for unsubstantiated diagnosis codes.[8] For example, chart reviewers would routinely not remove morbid obesity diagnostic codes that were not supported in the medical record.

Key Takeaways

From the Cigna settlement, key takeaways plans should consider include the following:
  1. Review and revise systematic processes that identify medical diagnoses for beneficiaries to ensure they conform with Medicare’s adopted International Classification of Disease (ICD) Official Guidelines Coding and Reporting.
  2. Refrain from submitting additional diagnostic codes when there is no supporting testing, imaging, or clinical assessments in the current medial record.
  3. If new conditions are identified and diagnostic codes added, reach out to the beneficiary and coordinate care to ensure treatment is received.
  4. Revise chart-review programs to eliminate one-way chart reviews that only submit additional risk-adjusting diagnosis codes but do not withdraw codes not supported by the medical record or encounter data.
  5. Audit patient records to ensure current risk adjustment data is corroborated by sufficient medical record documentation that includes care and treatment rendered or attempts by the MA plan to coordinate and secure care for the beneficiary for the diagnosis.
[1] U.S. Dep’t of Justice (DOJ), Press Release, Cigna Group to Pay $172 Million to Resolve False Claims Act Allegations (2023), https://www.justice.gov/opa/pr/cigna-group-pay-172-million-resolve-false-claims-act-allegations.
[2] Id.
[3] U.S. Dep’t of Health and Human Servs., Office of Inspector Gen., The Cigna Group Corporate Integrity Agreement (2023), https://oig.hhs.gov/fraud/cia/agreements/The_Cigna_Group_09292023.pdf.
[4] U.S. Attorney’s Office for the Southern District of New York, Press Release, United States Reaches $37 Million Settlement Of Fraud Lawsuit Against Cigna For Submitting False And Invalid Diagnosis Codes To Artificially Inflate Its Medicare Advantage Payments (2023), https://www.justice.gov/usao-sdny/pr/united-states-reaches-37-million-settlement-fraud-lawsuit-against-cigna-submitting.
[5] Id.
[6] DOJ, supra note 1.
[7] Id.
[8] Id.