Home Health & Hospice Week

Home health and hospice providers that lament managed care’s invasion of the Medicare market may want to keep tabs on a new lawsuit.

The United States has filed a civil healthcare fraud lawsuit against CIGNA Corp. and its subsidiary Medicare Advantage Organizations, seeking damages and penalties under the False Claims Act for CIGNA’s submissions of false and invalid patient diagnosis codes to artificially inflate the payments CIGNA received for providing insurance coverage to its MA plan members, the Department of Justice says in a release. The government is intervening in a whistleblower suit.

“As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting … false and invalid diagnoses for its Medicare Advantage plan members,” New York U.S. Attorney Damian Williams says in the release. “CIGNA knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker.”

CIGNA sent nurse practitioners and other non-physician practitioners into members’ homes to assess them with a “so-called ‘360 comprehensive assessment’” form for a variety of conditions related to lucrative diagnosis codes, the suit charges. The assessing staff spent limited time with the patient, didn’t conduct comprehensive medical exams, and didn’t have access to their full medical records, the DOJ says.

“CIGNA’s 360 home visit program regularly generated false and invalid diagnosis codes for certain serious, complex conditions that cannot be reliably diagnosed in a home setting and without extensive diagnostic testing or imaging,” according to the DOJ. And “CIGNA exerted pressure on [practitioners] to record high-value diagnoses that significantly increased risk adjustment payments,” it accuses.

“CIGNA improperly received tens of millions of dollars in risk adjustment payments from CMS, in violation of both the False Claims Act and the common law,” the DOJ charges.