Cigna: Checking the Box, Raising the Payment

The Cigna Medicare Advantage settlement required Cigna to pay $172,294,350 to resolve False Claims Act allegations of one-way chart review, unsupported home-visit diagnoses and false morbid-obesity coding. For a clinician or coder, the telling detail is what happened after the home visit: Cigna’s coding team turned conditions checked on a form into diagnosis codes, and the company tracked how the diagnoses affected its Medicare payments.

The Justice Department announced the Medicare Advantage fraud resolution on September 30, 2023. The total includes the $37 million home-visit settlement, where Cigna made factual admissions about the forms, testing equipment and payment tracking behind the program.

Why the Diagnoses Increased Cigna’s Payments

Medicare Advantage pays private plans a monthly amount for each member, adjusted for expected health care costs. The Centers for Medicare and Medicaid Services uses diagnoses and demographic information to calculate a member’s risk score. A higher score means a higher payment to the plan.

In this risk-adjustment payment model, eligible diagnoses map to condition categories with values that contribute to the score. The score multiplies the plan’s base payment rate.

The 2015 working paper Upcoding or Selection? Evidence from Medicare on Squishy Risk Adjustment, hosted by Duke University, estimated that enrollees in private Medicare plans generated diagnosis-based risk scores 6% to 16% higher than they would have generated under fee-for-service Medicare. The paper describes how insurers can influence coding through chart reviews, provider training and home assessments.

The Practices Covered by the Cigna Settlement

One-Way Chart Review

For payment years 2014 through 2019, the government alleged that Cigna used one-way chart review to increase payments while keeping unsupported codes in place. Cigna obtained records from providers and hired coders to identify diagnoses the providers had not reported. Those additions went to Medicare.

The same reviews also failed to substantiate some diagnoses already submitted. According to the government, Cigna did not delete or withdraw those codes, which would have required repayment. The review counted when it found more money for Cigna. Its contrary findings did not receive the same treatment.

The pattern also appeared in HealthCare Partners’ settlement. There, the government resolved a whistleblower’s allegations that the company searched records for missed diagnoses to send to insurers while ignoring inaccurate codes that should have been deleted. An insider can see both outputs of a review, even when the payment system receives only the additions.

Home-Visit Diagnoses

The home-visit allegations concerned diagnoses drawn solely from assessments by paid vendors. Nurse practitioners typically conducted the visits, with registered nurses and physician assistants also conducting some assessments. The government alleged that these providers did not perform or order the testing or imaging necessary to establish the serious conditions they reported. The forms lacked supporting information, and no other provider who saw the member reported those diagnoses to Cigna during the same year.

Morbid-Obesity Codes

For payment years 2016 through 2021, the government alleged that Cigna submitted or retained false morbid-obesity codes for members whose records lacked a body mass index of 35 or above. Those codes increased Medicare payments.

This unsupported-diagnosis allegation turned on the recorded body mass index and the higher-paying diagnosis Cigna submitted or left in place.

Inside Cigna’s 360 Home-Visit Program

The Middle District of Tennessee’s settlement account describes a program allegedly built around capturing diagnoses that increased payments. Cigna’s 360 comprehensive assessment used a company-created, multipage form listing conditions for the visiting clinician to check. Coding teams then translated those entries into codes for submission to the Centers for Medicare and Medicaid Services.

According to the government’s account of an internal Cigna document, the visits’ primary goal was capturing codes, not managing chronic or acute care. The government alleged that members were not told this when the visits were scheduled or conducted.

The government alleged that Cigna selected members likely to produce the greatest risk-score increases. The vendor healthcare providers relied largely on patients’ self-reports and basic screening questions, without access to their full medical histories or a comprehensive examination.

The alleged pressure came from above the individual visit. Management identified at least 12 classes of chronic diagnoses it considered underdiagnosed and pushed them in vendor trainings and seminars. Cigna tracked the volume and type of diagnoses each vendor generated and requested performance improvement plans for providers who captured fewer diagnoses than expected.

According to an internal report described by the government, one vendor’s 6,658 visits in the first nine months of 2014 generated more than $14 million in additional Medicare payments, against approximately $2.13 million paid to the vendor.

For someone working inside a vendor, the selection criteria, training instructions and performance reports show a part of the program that a completed assessment alone cannot. They connect what the clinician recorded to what the insurer wanted the visits to produce.

When the Form Undermined the Diagnosis

The government alleged that some 360 forms contained findings that contradicted the diagnoses submitted. Its heart-failure example involved a form describing the patient’s heart as regular and normal, with an unremarkable cardiac review, alongside a congestive heart failure diagnosis.

The conditions in the government’s account also included chronic kidney disease, rheumatoid arthritis and diabetes with renal complications. The allegations concerned the missing diagnostic support, the testing the conditions required and what the forms actually recorded.

Cigna’s annual certification of its diagnosis data was another part of the alleged conduct. The government said Cigna certified the data as accurate, complete and truthful while submitting these unsupported diagnoses. The chain reached from the clinician’s form through the coding team to the insurer’s submission and certification.

The Whistleblower Award Belonged to the Home-Visit Case

The whistleblower was a former part-owner of a vendor Cigna retained to conduct home visits. The national announcement allocated an $8.14 million reward from the settlement of the home-visit allegations.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

This case shows why vendor knowledge matters. The insurer’s own employees were not the only people positioned to understand how the visits worked.

Cigna’s Admissions Reached the Forms and the Equipment

In the home-visit settlement, Cigna admitted that its vendors used standardized forms and that its coding team mapped the checked conditions to diagnosis codes submitted to Medicare. It admitted that providers were, in many cases, not permitted to provide treatment or prescriptions. It also admitted tracking both the diagnoses and their effect on risk-adjusted payments.

That treatment restriction mattered to the government’s case. The government alleged that the diagnoses did not affect patient care, treatment or management during the visit, as coding guidelines required, making them ineligible for risk adjustment.

Cigna’s own diagnostic criteria called for laboratory evaluation, imaging or other testing when first diagnosing some conditions. Yet Cigna admitted that, in many cases, it did not require home-visit vendors to have the equipment to perform that testing. Serious diagnoses were welcome. The equipment needed to make them was often optional.

Cigna also admitted that, in many instances, it reported diagnoses when the forms lacked corroborating clinical information and did not show that the testing necessary for an initial diagnosis had occurred.

The resolution also brought a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General. It requires annual certifications by top executives and board members and independent audits of risk-adjustment data.

The Industry Incentive Behind the Home Visit

In its 2021 evaluation of both practices, the Office of Inspector General found that 20 of 162 Medicare Advantage companies drove a disproportionate share of $9.2 billion in payments from diagnoses reported only on chart reviews and health risk assessments, with no other service records. The agency raised concerns about diagnosis validity and the coordination of care when vendors conducted assessments outside the patient’s usual care team.

A 2024 presentation reporting an Urban Institute expert workgroup’s findings put the incentive plainly:

The presentation identified home health risk assessments and chart reviews as practices plans use to maximize risk-adjustment payments. Cigna’s admissions show what that incentive looked like on a form: a condition checked, missing support for the diagnosis and a code sent for payment. Taxpayers financed the resulting increase.

You Saw What the Visit Was Expected to Produce

If you saw vendor targets, unsupported diagnoses or review findings that never became corrections, tell our whistleblower experts how the program worked. We connect the clinical, coding and payment evidence with you, bring in Medicare Advantage whistleblower lawyers who understand risk-adjustment cases, and stay alongside you through the case.