Cigna has agreed to pay $172,294,350 to settle allegations that it violated the False Claims Act, including submitting diagnosis codes unsupported by necessary medical imaging, authorities announced Saturday.
Under the Medicare Advantage program, the Bloomfield, Connecticut-based insurer would purportedly base such diagnoses on in-home patient assessments of beneficiaries typically conducted by nurse practitioners. These NPs would often diagnose serious, complex conditions without the necessary medical imaging or diagnostic tests to reach such conclusions, the Department of Justice said.
Other healthcare providers who saw these patients did not report such diagnoses to Cigna during the year in which the home visits occurred.
“For years, Cigna submitted to the government false and invalid diagnosis information for its Medicare Advantage plan members,” Damian Williams, U.S. Attorney for the Southern District of New York, said in a Sept. 30 announcement from the DOJ. “The reported diagnoses of serious and complex conditions were based solely on cursory in-home assessments by providers who did not perform necessary diagnostic testing and imaging. Cigna knew that these diagnoses would increase its Medicare Advantage payments by making its plan members appear sicker.”
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