In August, the complaint in a federal whistleblower lawsuit against Cigna was unsealed. In it, Cigna is accused of collecting billions of dollars in overpayments from its HealthSpring Medicare Advantage plans. How could a health insurance company seem to carry out fraud on such as massive scale, you ask? Well, here’s the scoop. Insurers that run MA plans receive monthly payments from the government to cover the cost of their members’ care. Put simply, these payments are bigger for high risk (i.e. sicker) plan members and smaller for those deemed low risk (i.e. healthier). In this suit, Cigna is accused of implementing a program designed to raise the risk scores of its plan members to solicit larger payments from CMS. According to the suit, Cigna allegedly sent nurses into patients’ homes to conduct health assessments intended to result in higher risk scores for those patients. The company allegedly pushed these providers to see as many as 35 patients per week and mandated that they generate 20 or more diagnoses per visit. If that weren’t shocking enough, the suit also alleges that Cigna didn’t allow these providers to offer care, prescribe medicine, or make specialist referrals. If the claims in this suit are true, not only did Cigna defraud the government on a massive scale, it also prevented its MA plan members from receiving care—and providers from delivering care. This is not the first time Cigna has faced such accusations, and we’d be shocked if it will be last. The real question, however, is if Cigna will face any real consequences for this behavior.
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