Home Health & Hospice Week

Bogus in-home assessments are part of the reason insurer Cigna has agreed to a big fraud settlement.

The Cigna Group will pay $172 million to “resolve allegations that it violated the False Claims Act by submitting and failing to withdraw inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan enrollees in order to increase its payments from Medicare,” the Justice Department says.

“Cigna reported diagnosis codes … that were based solely on forms completed by vendors retained and paid by Cigna to conduct in-home assessments of plan members,” the DOJ explains in a release. “The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the diagnostic testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported, and were in many cases prohibited by Cigna from providing any treatment during the home visits for the medical conditions they purportedly found,” it adds.

“The diagnoses at issue were not supported by the information documented on the forms completed by the vendors and were not reported to Cigna by any other healthcare provider who saw the patient during the year in which the home visit occurred,” the Justice Department says. “Nevertheless, Cigna submitted these diagnoses to CMS to claim increased payments.”

In addition to the financial settlement, the insurer has entered into a five-year Corporate Integrity Agreement with HHS under which requires “top executives and members of the Board of Directors [to] make certifications about Cigna’s compliance measures” and independent audits, among other steps.