Health insurance concept, insurance form with stethoscope
Health insurance form. Credit: Vitalii Vodolazskyi / Shutterstock

Connecticut-based health insurer The Cigna Group has agreed to pay a more than $172 million settlement to resolve allegations by the federal government that it submitted “untruthful” diagnosis information to boost its Medicare payments, according to the Justice Department.

The settlement relates to the DOJ’s assertion that Cigna violated the False Claims Act by submitting false diagnosis codes for patients enrolled in its Medicare Advantage Plan, sometimes called Medicare Part C. 

Under the program, patients receive Medicare benefits through a private company like Cigna, which is paid by the government based on a number of risk factors. In this case, the government accused Cigna of trumping up those risk factors by reporting incorrect diagnosis information then failing to withdraw those claims. 

“Over half of our nation’s Medicare beneficiaries are now enrolled in Medicare Advantage plans, and the government pays private insurers over $450 billion each year to provide for their care,” Deputy Assistant Attorney General Michael D. Granston said in a Monday press release.  “We will hold accountable those insurers who knowingly seek inflated Medicare payments by manipulating beneficiary diagnoses or any other applicable requirements.”

In a separate press release Friday, Chris DeRosa, president of Cigna Healthcare’s U.S. government business, said the agreement would allow the insurer to “move beyond industry-wide legal disputes related to past risk adjustment practices” and focus on delivering value to customers and taxpayers.

“We hold ourselves to high standards for serving Medicare beneficiaries and all of our customers, and are constantly evaluating and evolving our processes accordingly,” DeRosa said. “This resolution provides us another important tool to gain insights and further improve our support for beneficiaries and we look forward to continuing our collaborative and constructive relationship with the government. Above all, our focus remains on improving the health and vitality of all those we serve.”

According to the DOJ, Cigna conducted a review of payments between 2014 and 2019, which did not back up some of the diagnosis codes submitted to the Centers for Medicare and Medicaid Services and declined to withdraw the claims and reimburse the government. 

Meanwhile, the Justice Department accused Cigna of knowingly submitting incorrect diagnosis information between 2016 and 2021 claiming that certain patients were morbidly obese without substantiating those claims through Body Mass Index test results. 

The government also accused Cigna of submitting diagnosis information based on paperwork filled out by home visit vendors who did not perform the necessary testing to reliably substantiate the diagnosis information. The settlement included more than $8.1 million for Robert Cutler, a former home visit vendor, who served as a whistleblower and filed a lawsuit on behalf of the United States. 

In addition to paying $172,294,350 to resolve the allegations, Cigna agreed to enter a five-year Corporate Integrity Agreement with the U.S. Department of Health and Human Services Office of Inspector General, according to the press release. The agreement requires the insurers board of directors to annually attest to Cigna’s compliance and conduct audits and risk assessments. 

“Medicare Advantage plans that submit false information to increase payments from CMS show blatant disregard for the integrity of these vital federal health care funds,” Christian J. Schrank, Deputy Inspector General for Investigations with HHS-OIG, said. “Such actions are an affront to the Medicare program and the millions of patients who rely on its services.”