Lawsuit Alleges Cigna Upcoded Tens of Thousands of Medicare Advantage Claims

The U.S. Department of Justice has joined a whistleblower lawsuit accusing Cigna Corp. of overbilling Medicare Advantage by submitting false patient diagnosis information to inflate payments The lawsuit seeks damages and penalties under the False Claims Act. The whistleblower lawsuit originally was filed in 2017 in the United States District Court for the Southern District of New York and later transferred to the Middle District of Tennessee.

The complaint alleges that from 2012 to 2019 Cigna submitted false and invalid diagnoses of certain serious and chronic medical conditions that were based solely on forms completed during visits to patients’ homes conducted by vendors retained and paid by Cigna and that Cigna knew the following:

  • The healthcare providers who conducted these home visits did not perform or order the testing, imaging, or other diagnostic steps needed to reliably diagnose these conditions.
  • The patients did not receive any treatment for the purported medical conditions during the home visits.
  • No other healthcare providers, such as the patients’ primary care physicians, had diagnosed or treated the patients for these medical conditions during the year in which the home visits occurred.
  • These diagnoses did not comply with CMS’s requirements for coding diagnoses.

Nevertheless, defendants submitted these diagnoses to CMS to claim increased payments, and falsely certified on an annual basis that their diagnosis data submissions were “accurate, complete, and truthful,” according to the complaint.

“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. Cigna knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker,” said U.S. Attorney Damian Williams in a news release.

Under Medicare Part C, Medicare Advantage Organizations (MAOs), typically operated by private insurers, provide coverage for Medicare beneficiaries. In return, MAOs receive capitated payments from the Centers for Medicare and Medicaid Services (CMS) based on demographic information and the diagnoses of each plan beneficiary. 

MAOs submit diagnosis data, typically passed along from beneficiaries’ healthcare providers to CMS. CMS then uses that data, along with demographic factors, to calculate a “risk score” for each beneficiary and, in turn, the amount of the monthly capitated payment that the MAO will receive for covering that beneficiary. The Medicare Advantage payment model is intended to pay MAOs more to provide healthcare for sicker enrollees who are expected to incur higher healthcare costs.

The alleged violations took place as part of Cigna’s so-called “360 comprehensive assessment” program. Home visits typically were conducted by nurse practitioners, or other non-physician healthcare providers such as registered nurses and physician assistants. The complaint alleges that the purpose of the visits was not to treat patients’ medical conditions, and that Cigna explicitly prohibited the healthcare professionals from providing actual patient treatment or care. The complaint also alleges that when identifying plan members to receive home visits, Cigna targeted patients who were likely to yield the greatest risk score increases and thus the greatest increased payment.  

For example, according to an internal report, Cigna determined that, during the first nine months of 2014, one vendor’s 6,658 in-home visits resulted in more than an additional $14 million in Medicare payments, significantly less than the approximately $2.13 million that Cigna paid to the healthcare providers. When specific providers were found to have captured fewer diagnoses than expected, Cigna asked the vendor to prepare a “performance improvement plan” for the provider, according to the government.

The invalid diagnosis included, but are not limited to, complex medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications, conditions that could not be diagnosed in a home setting or without extensive diagnostic testing or imaging. 

The complaint alleges that not only did the misconduct allow Cigna to obtain and retain artificially inflated risk adjustment payments from CMS, it also adversely affected the integrity and accuracy of CMS’s risk adjustment payment system.

The whistleblower is identified as Robert A. Cutler, an employee of Cigna contractor Texas Health Management LLC.

The Health Law Offices of Anthony C. Vitale handles matters relating to whistleblower representation as well as Medicare and Medicaid fraud defense. For more information, contact us at 305-358-4500 or email

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The Health Law Offices of Anthony C. Vitale