HARTFORD, CT – Healthcare insurer Cigna has agreed to pay $172,294,350 to settle allegations that it submitted fraudulent diagnosis codes to inflate Medicare Advantage payments. The Connecticut-based company allegedly violated the False Claims Act by providing inaccurate and untruthful data related to its Medicare Advantage Plan enrollees to the Centers for Medicare and Medicaid Services (CMS).
Under Medicare Advantage, also known as Medicare Part C, private insurance companies receive fixed monthly payments from CMS for each enrolled beneficiary. These payments are adjusted based on various health risk factors. The United States claimed that Cigna knowingly submitted false data to increase its payments and failed to correct these inaccuracies.
The settlement comes after an investigation covering payment years from 2014 to 2021. The government alleges that Cigna operated a “chart review” program that improperly used medical records to submit additional diagnosis codes, thereby inflating payments. Moreover, Cigna did not delete or correct codes that were found to be inaccurate, which would have required repayment to CMS.
Deputy Assistant Attorney General Michael D. Granston emphasized the government’s commitment to holding insurers accountable for manipulating Medicare payments. The settlement also includes Cigna entering a five-year Corporate Integrity Agreement with the U.S. Department of Health and Human Services Office of Inspector General, mandating various accountability measures and independent audits.
The civil settlement resolves a whistleblower lawsuit filed by Robert A. Cutler, a former part-owner of a vendor used by Cigna for home visits. Cutler will receive $8,140,000 as part of the settlement.