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Government Intervenes in Whistleblower’s Case Against Cigna’s Medicare Advantage Organizations

October 18, 2022.  The United States Department of Justice intervened in a case against insurer Cigna and its Medicare Advantage Organization (MAO) subsidiaries.  Per the complaint, the MAOs allegedly earned “tens of millions of dollars” in false claims for its Medicare Advantage business.  The whistleblower is an attorney and former employee of one of the vendors that Cigna employed in its scheme.  If the lawsuit is successful, the whistleblower is entitled to 15-25% of the government’s recovery.

According to the complaint, Cigna engaged in a concerted effort to add the most lucrative diagnosis codes to Medicare Advantage beneficiaries’ charts to get higher risk adjustment payments from the Centers for Medicare and Medicaid Services (CMS) for those patients—without providing diagnostic testing to support those diagnoses.  From 2012-2019, the whistleblower alleges that Cigna’s MAO subsidiaries hired outside medical vendors to visit Medicare Advantage beneficiaries’ homes as part of a “360 comprehensive assessment program.”  Cigna MAOs administer Medicare Part C plans in 25 states across the country, encompassing over 500,000 beneficiaries, according to the complaint.  To reach all those beneficiaries, the MAOs hired non-physician healthcare providers to visit their Medicare Advantage plan members.  The non-physician healthcare providers visited members at their homes and conducted an assessment based on a questionnaire Cigna produced.  These providers were “explicitly prohibited […] from providing actual patient treatment or care” and instead were instructed to diagnose beneficiaries with conditions that “could not be reliably diagnosed in a home setting and without extensive diagnostic testing or imaging.”

From these home visits, patients accumulated “Invalid Diagnoses,” or diagnoses not supported by testing, previous records, or other healthcare providers.  Cigna allegedly submitted these diagnoses to CMS, garnering higher capitated payments for their Medicare Part C beneficiaries than these beneficiaries warranted.  The complaint further alleges that Cigna paid close attention to the vendors’ performance in generating high value diagnosis codes, putting vendors who did not gin up as many codes as others on “performance improvement plan[s].”  Additionally, the diagnoses captured during the 360 home visits were supposed to “affect patient care, treatment, or management,” which they did not, in one of several violations of the International Classification of Diseases (“ICD”) Office Guidelines for Coding and Reporting that sprang from these home visits.  For knowingly submitting these Invalid Diagnoses to CMS and certifying that the information they provided about their Medicare Part C members was “accurate, complete, and truthful,” the whistleblower alleged that Cigna violated the False Claims Act.  The government investigated the whistleblower’s complaints and decided to intervene in the qui tam suit.

Medicare Advantage, or Medicare Part C, is a taxpayer-funded program whereby private insurers provide Medicare hospital, physician, and pharmacy benefits to eligible citizens through Medicare Advantage Organizations.  The private insurers who operate MAOs receive diagnosis information from the Medicare beneficiaries’ healthcare providers and send that information to CMS.  CMS pays MAOs a per-head or capitated amount for each beneficiary, which is adjusted based on the beneficiary’s medical conditions and demographic information.  CMS pays more for sicker patients through risk adjustment payments, which some fraudsters see as incentive to falsely inflate diagnosis codes.

Medicare Advantage fraud harms taxpayers, patients, medical providers, and health insurers.  In this case, it was a waste of taxpayer resources to send medical professionals to mine for diagnosis codes instead of providing actual care.  The more money CMS pays to insurers for fraudulent diagnoses, the less money is available to pay for care for patients who have serious, life-threatening diagnoses.  These costs are passed back to taxpayers, who unfortunately fund false and real claims alike.  When whistleblowers speak up about Medicare Advantage fraud, they ensure taxpayer dollars are funding healthcare, not get-rich-quick schemes.

If you would like to report Medicare Advantage fraud, you can contact attorneys at Tycko & Zavareei LLP.  Eva Gunasekera and Renée Brooker are former officials of the United States Department of Justice and prosecuted whistleblower cases under the False Claims Act. Eva was the Senior Counsel for Health Care Fraud. Renée served as Assistant Director at the United States Department of Justice, the office that supervises False Claims Act cases in all 94 United States District Courts. Eva and Renée now represent whistleblowers. For a free consultation, you can contact Eva Gunasekera at [email protected] or contact Renée at [email protected] (tel.: 202-417-3664). Visit Tycko & Zavareei LLP’s website for whistleblowers to learn more at

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