Cigna Group will pay $172.3 million to settle allegations that it exaggerated its members' illnesses to collect excess Medicare Advantage payments.
The agreement follows a Justice Department investigation into Cigna's chart reviews and home health visits and a separate whistleblower lawsuit. Cigna does not admit to violating the False Claims Act by agreeing to the settlement, according to a news release the Justice Department issued Friday.
"These agreements fully resolve long-running legal matters, enabling us to focus our resources on all those we serve and avoiding the uncertainty and further expense of protracted litigation," Chris DeRosa, president of Cigna Healthcare's government business, said in a news release on Friday. Cigna recently completed a successful federal Medicare Advantage audit, according to the news release.
The Justice Department and the attorneys general of New York and Tennessee attorneys filed a lawsuit last year in the U.S. District Court for the Middle District of Tennessee that accused Cigna of improperly boosting Medicare Advantage reimbursements. According to prosecutors, the company falsely documented home health services that were not performed and routinely added diagnoses to Medicare Advantage claims from 2014 to 2019. The lawsuit further alleged that Cigna improperly categorized some beneficiaries as morbidly obese from 2016 to 2021.
The deal also ends a whistleblower lawsuit that accused Cigna of submitting improper diagnostic codes for home health services from 2012 to 2019. Robert Cutler, a former vendor for Cigna subsidiary HealthSpring, filed his case in 2017 and the Justice Department joined it last year. Cutler will receive $8.1 million from the settlement, according to the Justice Department.
Under the settlement, Cigna accepted a five-year corporate integrity agreement with the Health and Human Services Office of Inspector General. Among the stipulations are that an independent auditor must review patient information the company submits to the Centers for Medicare and Medicaid Services and that executives and directors must certify compliance.
The U.S. has targeted multiple health insurance companies with Medicare Advantage False Claims Act lawsuits and this year initiated a revamp of the risk-adjustment system used to document patient conditions.