Removing Ambiguity from CMS’s In-Home HRA Guidance: Lessons from Cigna’s $172 Million False Claims Act Settlement
By Admin | December 22, 2023
December 22, 2023 | By: Edward Baker, Of Counsel | Lieff Cabraser Heimann & Bernstein
On September 30, 2023, the U.S. Department of Justice announced a $172 million False Claims Act (FCA) settlement with Cigna relating to the submission of invalid HCC diagnosis codes to CMS in order to increase Medicare Advantage member risk scores, and therefore, risk adjustment payments.
It is one of the largest FCA settlements involving MA risk adjustment fraud to date and the third this year. Much of the settlement ($37 million) relates to invalid HCC diagnosis codes generated from in-home health risk assessments (HRAs). This is part of the case initiated by a whistleblower, Robert A. Cutler, a former service provider to a Cigna affiliate, who will receive $8.1 million for bringing these allegations to the Government’s attention.
As a former Assistant U.S. Attorney and now a private attorney for whistleblowers, one of the things that caught my attention about this particular settlement (besides the large whistleblower reward!) is that Cigna admitted engaging in fraudulent conduct in the settlement agreement itself. That doesn’t always happen. Frequently, the DOJ does not require a defendant to admit to wrongdoing to settle an FCA case. They simply let the money paid by the defendant speak for itself and impose a Corporate Integrity Agreement to deter the defendant from engaging in the misconduct again. But in this instance, Cigna admitted to some of the fraudulent conduct alleged by the Government and the whistleblower.
Most notably, Cigna admitted that it engaged in three types of wrongful conduct. First, Cigna admitted that it gave vendors (typically NPs and RNs) specific diagnostic criteria to look for when conducting in-home HRAs of MA plan members, such as major depressive disorder, but the clinical assessment for some of the diagnoses “relie[d] on laboratory evaluation, diagnostic imaging, or other diagnostic testing” when making the diagnoses for the first time.
That would have been fine, except that Cigna did not require the vendors conducting the in-home HRAs “to have the equipment available to conduct such laboratory testing, imaging, or other diagnostic testing when diagnosing these conditions.” In other words, the vendors hired by Cigna to perform...(More)
For more info please read, Removing Ambiguity from CMS’s In-Home HRA Guidance: Lessons from Cigna’s $172 Million False Claims Act Settlement, by NAMAS
