Cigna Medicare Advantage Scandal Explained

Cigna is a health care and insurance company that is based in the city of Bloomfield Connecticut. It is publicly traded on the New York Stock Exchange (NYSE) and is a part of the S&P 500.

David Cordani is the Chairman, President, and CEO of Cigna. The company had $174.1 billion in revenue in 2021 and employs 73,800 people.

Cigna has been accused in a whistleblower lawsuit and a federal lawsuit of getting millions in payments from the federal Medicare Advantage program by inflating the severity of diagnoses of its patients.

Whistleblower Lawsuit Filed Against Cigna In 2017

In 2017 whistleblower Robert Cutler filed a lawsuit against Cigna and its affiliates, alleging Medicare fraud.

Cutler was an officer at Texas Health Management LLC, a service provider for Cigna-HealthSpring.

The lawsuit claimed that Cigna’s home visit program (called the 360 program) for Medicare patients artificially inflated the payments it received from the federal government by incorrectly diagnosing thousands of patients with severe illnesses.

The suit said Cigna sent nurse practitioners to patients homes and made diagnoses based on anecdotal evidence instead of an independent diagnosis made by a trained physician.

Cutler’s suit alleged that Cigna bilked $1.4 billion from Medicare from 2012 to 2017 using illicit practices.

The lawsuit was filed as United States of America, ex. rel. Robert A. Cutler v. Cigna Corp. et al., Case No. 7:17-cv-07515 and was filed in the U.S. District Court for the Southern District of New York.

In 2020, the Department of Justice – then led by Attorney General William Barr, appointed by President Donald Trump, declined to intervene in the lawsuit.

Department Of Justice Filed Civil Fraud Lawsuit Against Cigna

In October 2021, the Department of Justice (led by Attorney General Merrick Garland) filed a civil fraud lawsuit against Cigna. The action was official government intervention in Cutler’s earlier lawsuit.

The case is United States of America vs. Cigna Corporation.

The Department alleged that Cigna owed penalties to the federal government under the False Claims Act “for CIGNA’s submissions to the Government of false and invalid patient diagnosis codes to artificially inflate the payments CIGNA received for providing insurance coverage to its Medicare Advantage plan members.”

DOJ echoed Cutler’s earlier allegations. Damian Williams, United States Attorney for the Southern District of New York, said, “As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members.”

The government alleged that Cigna structured home visits under its 360 program for “the primary purpose of capturing and recording lucrative diagnosis codes” that would increase the monthly payments it received from the taxpayer funded Centers for Medicare and Medicaid Services.

The suit claimed that one Cigna executive referred to the company looking for “golden nuggets” to file Medicare claims over. The “nuggets” meant “conditions such as diabetes with complications, major depression, and vascular disease.”

According to the government, Cigna “spent about $18.8 million on home visits for a projected profit of about $61.8 million for 2014.”

The DOJ noted in its release about the lawsuit that in one case, a patient received a diagnosis of congestive heart failure but the notations from the physical exam done for the same patient said her heart was “regular” and normal” and “cardiac reviewed and unremarkable.”

Cigna Denied Allegations

Cigna denied the allegations made against the company in the federal lawsuit.

In a statement Cigna said, “We will actively defend Cigna against unjustified allegations.” The company also noted, “We are proud of our industry-leading Medicare Advantage program and the manner in which we conduct our business.”