PHILADELPHIA, Pa.- The health insurance company Independence Blue Cross will pay $22.5 million to settle allegations that it purposely inflated diagnoses for financial gain, the U.S. Department of Justice (DOJ) said.

The civil settlement resolves a lawsuit filed under the whistleblower provisions of the False Claims Act.

According to the DOJ, for payment years 2017-2021, Independence Blue Cross (IBX) knowingly used inaccurate and untruthful diagnosis codes for some Medicare Advantage Plan enrollees, resulting in overpayments from Medicare.

The DOJ alleges that IBX operated a “chart review” program in which its nurse reviewers looked over medical records (charts) and identified all medical conditions that the charts supported.

IBX relied on the results of those chart reviews to submit additional diagnosis codes to the Centers for Medicare & Medicaid Services (CMS) to obtain additional payments, federal investigators said.

However, IBX’s chart reviews allegedly did not substantiate some diagnosis codes previously reported by IBX to CMS; IBX did not delete or withdraw those codes, which would have required IBX to reimburse CMS.

Further, the DOJ contends that Independence Blue Cross used the results of its chart reviews to identify instances where it could seek additional payments from CMS, while ignoring those same results when they indicated IBX was overpaid.

“The government pays private insurers over $530 billion each year to care for Americans enrolled in Medicare...

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