{"id":5035,"date":"2022-11-09T09:00:11","date_gmt":"2022-11-09T15:00:11","guid":{"rendered":"https:\/\/blogs.luc.edu\/compliance\/?p=5035"},"modified":"2022-11-09T09:00:11","modified_gmt":"2022-11-09T15:00:11","slug":"the-sicker-the-better-cigna-orchestrates-fraudulent-scheme-to-defraud-government","status":"publish","type":"post","link":"https:\/\/blogs.luc.edu\/compliance\/?p=5035","title":{"rendered":"The Sicker, The Better: Cigna Orchestrates Fraudulent Scheme to Defraud Government"},"content":{"rendered":"

Jake Parentis<\/em><\/p>\n

Associate Editor<\/em><\/p>\n

Loyola University Chicago School of Law, JD 2024<\/em><\/p>\n

Cigna Corporation<\/a> (Cigna)\u2013a global juggernaut in the insurance arena\u2013faces a health care fraud lawsuit brought by the government under the federal False Claims Act (the FCA). By allegedly exaggerating patients\u2019 illnesses to boost its own risk scores<\/a>, Cigna secured inflated payments from the Medicare Advantage reimbursement system.<\/p>\n

<\/p>\n

\u00a0<\/strong>The anatomy of the scandal\u2013\u2013rigging the results <\/strong><\/p>\n

In a United States Department of Justice (a \u201cDOJ\u201d) news release<\/a>, Damian Williams, the United States Attorney for the Southern District of New York, estimated that Cigna, \u201cobtained tens of millions of dollars in Medicare funding\u201d when it purportedly submitted invalid diagnoses to the government. Cigna falsified medical information with clear knowledge that federal funding would increase contingent on the degree to which its Medicare members appeared sick.<\/p>\n

Through its subsidiaries and affiliates, Cigna operates several Medicare Advantage Organizations that administer Medicare Advantage Plans (MAPs). Contracting with mostly nurse practitioners (the Vendors), Cigna instructed its Vendors to conduct home visits of MAP members pursuant to its 360 comprehensive assessment<\/a> initiative. Based on their visits, the Vendors were tasked with completing a Cigna-created form, that included a laundry list of potential medical conditions. Subsequently, Cigna assigned its coding staff to identify diagnosis codes corresponding to the indicated medical conditions. Thereafter, Cigna submitted those codes to the Centers for Medicare and Medicaid services for risk adjustment evaluation.<\/p>\n

In its own internal documents\u2013which were never disclosed to the Vendors\u2013Cigna described the primary goal of a \u201c360 visit\u201d to be \u201cadministrative code capture and not chronic care or acute care management.\u201d Cigna also targeted individuals likely to yield the greatest risk score increases. The Vendors never conducted comprehensive physical examinations, and when completing the assessments and recording the diagnoses, the Vendor HCPs relied largely on the patient\u2019s own self-assessment and responses to screening questions. Additionally, Vendors were restricted access from the patients\u2019 full medical history. The DOJ<\/a> additionally noted that Cigna \u201cexerted pressure on the [Vendors] to record high-value diagnoses,\u201d encouraging the Vendors to remain keenly vigilant of \u201coften underdiagnosed\u201d conditions. Strikingly, Cigna even provided trainings to Vendors to improve their \u201cperformance\u201d when they failed to deliver certain amounts of high-value diagnosis codes.<\/p>\n

Thus, the government’s complaint<\/a> details that in tens of thousands of instances, Cigna submitted a variety of markedly complex diagnoses to the government, including medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications. Also, notably, according to Cigna\u2019s own clinical guidelines, such conditions can only be accurately diagnosed through specialized testing, which cannot be administered in a patient\u2019s home.<\/p>\n

Denying the allegations in their entirety, Cigna released the following statement<\/a>: \u201cWe reject these allegations and will vigorously defend our Medicare Advantage business against them. Our focus remains on serving our Medicare customers and advancing our mission of making health care more affordable, predictable and simple for all.\u201d<\/p>\n

Medicare\u2019s exploitation\u2013\u2013A widespread concern?\u00a0 <\/strong><\/p>\n

According to government watchdog MedPAC<\/a>, Medicare Advantage enrollment has doubled since 2013, to about 28.8 million, or nearly 49% of all eligible Medicare beneficiaries. The New York Times<\/a> reported that Medicare Advantage overbilling\u2013due to upcoding\u2013is so endemic (possibly up to $25 billion) that it amounts to nearly the entire NASA budget ($21.5 billion) and more than twice the Environmental Protection Agency\u2019s budget ($8.7 billion). The Cigna scandal is just the latest in a series of related cases in which insurers have exploited Medicare for billions combined. For example, in 2021, the DOJ filed a complaint<\/a> against Kaiser Permanente (Kaiser)\u2013one of the largest healthcare providers in the United States\u2013in which information leaked by an internal whistleblower suggested the health-care consortium defrauded Medicare out of nearly $1 billion.<\/p>\n

The complaint detailed a confounding chain of events including Kaiser executives meeting with doctors during their lunch breaks to encourage them to add additional illnesses to patients\u2019 medical records despite not examining them for weeks. Those executives would even reward the doctors administering new diagnoses with bottles of Champagne and paycheck bonuses. Dr. James Taylor\u2013a former coding expert<\/a> at Kaiser and one of the ten whistleblowers to expose the company\u2019s fraud, commented that \u201c[t]he cash monster was insatiable,\u201d describing Kaiser\u2019s ulterior, avaricious motive.<\/p>\n

On a broader scale, federal audits<\/a> found that eight of the ten largest Medicare Advantage insurers, representing as much as two-thirds of the larger market, have submitted inflated bills. And four of those five insurers, including UnitedHealth, Humana, Elevance, and Kaiser, have faced FCA lawsuits all involving allegations that \u201cefforts to overdiagnose their customers crossed the line into fraud.\u201d<\/p>\n

Analysts are skeptical<\/a> of any major legislative or regulatory changes on the horizon. \u201cMedicare Advantage overpayments are a political third rail,\u201d said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. \u201cThe big health care plans know it\u2019s wrong, and they know how to fix it, but they\u2019re making too much money to stop.\u201d Gilfillan<\/a>, proposing a solution, posited that \u201c[t]heir C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars\u00a0<\/strong>for plans.\u201d<\/p>\n

America\u2019s concentrated wealth continues to strangle its democracy and promote widespread fraud. Cigna\u2019s scheme is yet another example of how the nation\u2019s corporate governance system is plagued by continued executive manipulation. Those in power remain equipped and entrenched with an unprecedented degree of control. The floodgates remain open for corporate abuse. Change ought to be imminent, but it remains to be seen whether the DOJ can gain ground in its stand against corporate insurance fraud.<\/p>\n","protected":false},"excerpt":{"rendered":"

Cigna Corporation (Cigna)\u2013a global juggernaut in the insurance arena\u2013faces a health care fraud lawsuit brought by the government under the federal False Claims Act (the FCA). By allegedly exaggerating patients\u2019 illnesses to boost its own risk scores, Cigna secured inflated payments from the Medicare Advantage reimbursement system.<\/p>\n","protected":false},"author":155,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[29],"tags":[485,646,1010,1011],"class_list":["post-5035","post","type-post","status-publish","format-standard","hentry","category-fraud-abuse","tag-congress","tag-doj","tag-health-insurance","tag-health-insurance-fraud"],"_links":{"self":[{"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=\/wp\/v2\/posts\/5035","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=\/wp\/v2\/users\/155"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=5035"}],"version-history":[{"count":0,"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=\/wp\/v2\/posts\/5035\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=5035"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=5035"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.luc.edu\/compliance\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=5035"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}