Cigna: Profits Over Patients

Cigna was accused of submitting false diagnosis codes to inflate Medicare Advantage payments under the False Claims Act. Their "360 Program" utilized in-home assessments to generate unsupported diagnoses, aiming for higher risk-adjustment payments.

Federal investigators discovered that many diagnoses lacked proper medical-record support or necessary diagnostic testing. This fraudulent activity persisted over several years, leading to a substantial settlement that included a five-year corporate integrity agreement with stringent monitoring provisions.

They exploited Medicare's risk adjustment system to siphon millions, undermining the integrity of public healthcare funding.

Cigna allegedly deployed an algorithmic system, PxDx, to automatically deny over 300,000 claims within seconds, bypassing necessary human review and violating state and federal laws. ProPublica revealed that Cigna prioritized speed over accuracy, resulting in widespread claim denials without proper examination of patient files.

Notably, a single medical director was found to have denied 60,000 claims in just one month using the PxDx system. Lawsuits argue that this practice contravened California’s requirements for individualized claim reviews, highlighting a blatant disregard for patient rights and due process.

Their automated denial system turned patient claims into mere numbers, stripping away essential human oversight and fairness.

Cigna agreed to pay $37 million to settle allegations of submitting false and invalid diagnosis codes to inflate Medicare Advantage payments. The Department of Justice (DOJ) accused Cigna of knowingly submitting unsupported codes to the Centers for Medicare & Medicaid Services (CMS) to secure higher reimbursements.

Whistleblower reports revealed systemic manipulation of diagnosis data by Cigna’s coding teams, highlighting a pervasive culture of fraud within the organization. This settlement resolves claims brought under the False Claims Act, underscoring the severity of Cigna's fraudulent practices.

They manipulated diagnosis data to unlawfully enrich themselves at the expense of Medicare and its beneficiaries.

The American Medical Association (AMA) and numerous patients filed a lawsuit against Cigna, accusing the insurer of underpaying claims based on MultiPlan contracts. This underpayment exposed patients to balance billing, forcing them to cover the difference between Cigna's reimbursement rates and the actual costs.

Cigna allegedly ignored the agreed-upon MultiPlan contract rates, applying lower reimbursement rates instead. The lawsuit claims this practice violated the Employee Retirement Income Security Act (ERISA) and state consumer protection laws in New Jersey and Washington. While the AMA’s claims were dismissed, the patients’ lawsuits were allowed to proceed, highlighting ongoing issues with Cigna's payment practices.

They undermined physician agreements and burdened patients with unexpected medical costs.

A class-action lawsuit alleges that Cigna systematically denied claims without proper review using automated systems like PxDx. Plaintiffs argue that these automated denials violated contractual obligations and state insurance laws, causing significant financial and health-related hardships.

Investigations revealed that the appeals processes were often futile due to systemic automation bias, leaving patients with no viable recourse to contest improper denials. This lawsuit seeks damages for affected patients and an injunction to halt automated denial practices, aiming to enforce fair claims processing.

Their relentless automation of claim denials left patients defenseless against unjust financial burdens.

A whistleblower filed a Qui Tam lawsuit exposing Cigna’s use of inaccurate diagnosis codes for Medicare Advantage beneficiaries, leading to inflated payments from CMS. The whistleblower alleged that diagnoses from home visits were unsupported by clinical evidence, revealing systemic issues with Cigna’s risk adjustment practices.

As part of the False Claims Act settlement, the whistleblower received an $8 million reward, underscoring the gravity of the fraudulent activities within Cigna’s coding teams. This case highlights broader industry-wide scrutiny into Medicare fraud and the manipulation of risk adjustment data.

They rewarded fraudsters while defrauding Medicare and jeopardizing patient care.

Federal lawsuits allege that Cigna improperly rejected thousands of medically necessary claims using automated systems. Patients reported being denied coverage for essential procedures like ultrasounds despite clear medical necessity, indicating a systemic issue within Cigna's claims processing.

Investigations revealed that denials disproportionately impacted vulnerable populations, exacerbating healthcare disparities. In response, the House Energy and Commerce Committee launched an investigation into these practices, aiming to enforce stricter oversight and ensure fair treatment for all patients.

They denied essential care, particularly harming those who needed it most.

Cigna failed to withdraw inaccurate diagnosis codes submitted to CMS between 2016 and 2021, resulting in overpayments that the company did not repay. Diagnosis codes for conditions like morbid obesity were submitted without supporting BMI indicators, violating CMS rules requiring accurate reporting.

Federal prosecutors argued that Cigna's actions were a deliberate attempt to manipulate billing practices, knowingly submitting inaccurate data to secure higher reimbursements. The settlement required Cigna to implement stricter compliance measures moving forward, aiming to prevent future violations.

They ignored accurate reporting standards, allowing fraudulent overpayments to persist unchecked.

Multiple whistleblowers have alleged that Cigna manipulated risk adjustment data to maximize Medicare Advantage payments. These allegations span from the early-to-mid-2010s and have led to ongoing investigations as of late 2024.

Lawsuits claim that Cigna's coders were incentivized to add unsupported diagnoses during chart reviews, inflating risk scores and securing higher payments from Medicare. CMS audits revealed significant discrepancies between reported diagnoses and actual patient records, indicating a deliberate effort to defraud the system. These practices have drawn broader DOJ scrutiny into Medicare fraud across the insurance industry.

They distorted patient data to illegally boost Medicare profits, undermining trust in healthcare systems.

Over the last decade, patients have alleged that Cigna engaged in balance billing by refusing to honor contracted reimbursement rates with out-of-network providers. This practice left patients facing significant out-of-pocket costs after being misled about their coverage terms.

Advocacy groups argue that these practices violate consumer protection laws and undermine patient trust in insurance providers. State regulators have fined insurers for similar balance billing practices, highlighting a pervasive issue within the industry that Cigna is a part of.

They burdened patients with unexpected bills, eroding trust and financial stability.