Cigna falsified the health conditions of its Medicare Advantage plan members to coax CMS into making larger payments to the insurer on behalf of beneficiaries, a U.S. Justice Department lawsuit alleges.
Medicare Advantage organizations get reimbursed by Medicare based on a formula that takes into account the patient population’s acuity levels. Risk adjustment scores adjust for health conditions so that more reimbursement levels are higher for more costly or chronically ill populations.
The risk adjustment scores have become a source of potential fraud. If the scores are not accurately calculated, MA organizations can receive more reimbursement than their populations warrant. The scores are calculated by CMS based on information provided by the MA organization about the patients health conditions. If the health information provided by the MA organization is inaccurate, so too will be the risk adjustment scores derived by CMS.
Cigna uses a medical assessment system called “360” to assess the health condition of its patients, but this system did not require the providers to state whether the patient’s condition was derived from a clinical assessment or the patient’s subjective description.
CMS alleges that Cigna received an estimated $1.4 billion from 2012 to 2017 and DOJ is seeking equal to three times that amount in damages, along with a civil penalty of $11,000 for each violation.