Healthcare Giant Admits to False Patient Diagnoses
Introduction:
Damian Williams, the U.S. Attorney for the Southern District of New York, and Henry C. Leventis, the U.S. Attorney for the Middle District of Tennessee, have announced a significant settlement in a healthcare fraud lawsuit against CIGNA, a prominent health insurer. This $37 million settlement addresses allegations that CIGNA submitted false patient diagnosis codes to artificially boost Medicare Advantage plan payments. We delve into the details of this case and its implications.
The Allegations:
CIGNA’s Role in False Diagnosis Codes
The government’s allegations against CIGNA involve the submission of invalid diagnosis codes based on in-home assessments conducted by vendor healthcare providers. These codes led to inflated payments without proper medical support.
Settlement Terms:
CIGNA Agrees to Pay $37 Million and Implement Reforms
For settlement terms, approved by U.S. District Judge Eli Richardson, CIGNA will pay $37 million and has admitted to specific misconduct. Additionally, they have entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services, Office of Inspector General, requiring them to implement measures to ensure compliance.
CIGNA’s Tactics:
Manipulative Strategies Revealed
We detail how CIGNA allegedly structured in-home assessments to capture high-value diagnosis codes rather than treat patients’ medical conditions. The focus was on increasing risk-adjusted payments without providing essential care.
Invalid Diagnoses:
Examples of False and Unsupported Diagnoses
There was a list of severe, complex conditions CIGNA allegedly misdiagnosed through the in-home assessments. These diagnoses were based solely on the evaluations and lacked the required medical testing or imaging.
Pressure on Providers:
CIGNA’s Push for High-Value Diagnoses
They have explored how CIGNA encouraged healthcare providers to make specific high-value diagnoses during in-home visits and closely tracked the impact of these diagnoses on payments.
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