A Cigna whistleblower lawsuit under seal since 2017 was recently made public. The complaint alleges that the health services company submitted fraudulent claims to Medicare Advantage by misrepresenting diagnosis codes, overbilling more than $1.4 billion between 2012 and 2017.

The 2017 complaint, filed in the U.S. District Court for the Southern District of New York by Relator Robert C. against Cigna and several affiliates was ordered to be unsealed on April 10, 2020, following the government’s notice that it was declining to intervene in certain claims and would not intervene at the time with the remaining claims.

The Cigna Medicare whistleblower lawsuit, brought under the False Claims Act, now faces a motion by Cigna to transfer the case from the New York federal court to the Middle District of Tennessee.

In his letter opposing the defendant’s request to transfer venue, the plaintiff argues that procedurally, Cigna meets the minimum contacts rule for jurisdiction in New York and that Tennessee is not a more convenient forum. Robert maintains that just two of the nine named defendants have operations in Tennessee and by transferring the case, Robert says he would be unable to continue his representation as Relator on behalf of the government in the qui tam action.

Cigna Whistleblower Lawsuit Alleges Medicare Fraud

Specifically, Robert alleges in the complaint that Cigna-HealthSpring created something called the 360 Program to engage primary care providers by having them perform a health assessment on Cigna-HealthSpring members.

According to Robert, the program was designed to be “an ‘enhanced’ version of an annual wellness visit” but was actually based on a business model to raise plan members’ risk scores to increase the monthly payments. The complaint states that the health insurer “engineered a system for performing the 360 that would capture as many diagnoses as possible.”

The Cigna whistleblower lawsuit alleges that as part of the 360 Program, Cigna-HealthSpring sent nurse practitioners to visit members’ homes and render diagnoses based on anecdotal evidence, while lacking authority to make independent diagnoses without collaborating with a physician. Robert also claims that Cigna-HealthSpring encouraged falsifying diagnoses and reported health conditions that were not supported by medical documentation or reliable clinical information.

In the unsealed complaint, Robert asserts that he acquired knowledge of the alleged Medicare fraud based on his position as an officer of Texas Health Management LLC, a Cigna-HealthSpring service provider. He claims that he first became aware of “Cigna-HealthSpring’s misreporting of ICD codes as well as other misconduct” in early 2017.

What is Medicare Fraud?

Medicare fraud, like that alleged in Robert’s Cigna whistleblower lawsuit, is a serious matter which the Centers for Medicare and Medicaid Services (CMS) says can potentially cost taxpayers billions of dollars and risk the health of Medicare beneficiaries.

According to CMS, Medicare fraud schemes can be committed by one person or involve an institution and can include activities ranging from knowingly submitting false claims to receiving or offering illegal kickbacks and making prohibited referrals. Some examples of Medicare fraud include billing for services not provided, billing for missed appointments, and falsifying records.

Medicare fraud claims can be brought under several different federal statutes, including the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Law, the Criminal Health Care Fraud Statute, and several other regulations. Criminal, civil, and administrative penalties can be imposed for those who are found to have committed Medicare fraud, in the form of substantial monetary penalties and imprisonment, depending on the statute the claim is brought under.

What Protections Do Medicare Fraud Whistleblowers Have?

The False Claims Act offers legal protections for those who discover Medicare fraudand file a whistleblower lawsuit on behalf of the government. If an employee is subjected to discrimination or retaliation as the result of filing a whistleblower lawsuit against an employer, the employee may be entitled to relief including reinstatement to their position, double the amount of back pay, special damages, and litigation fees.

Additionally, the False Claims Act requires that qui tam complaints are under seal for the first 60 days after the whistleblower files it, although the duration for which the suit is under seal can be extended. This gives the government an opportunity to investigate the claims and decide whether it is going to intervene.

A whistleblower cannot disclose the lawsuit to anyone while it is sealed to prevent the defendant from finding out about the investigation.

Under federal law, a Medicare whistleblower may be eligible to receive a financial award if the information they supply about the Medicare fraud leads to a monetary recovery.

Some states also provide additional protections for whistleblowers who report Medicare and Medicaid fraud. A whistleblower attorney can discuss your legal protections and rights to compensation.

The Cigna Whistleblower Lawsuit is United States of America, ex. rel. Robert A. Cutler v. Cigna Corp. et al., Case No. 7:17-cv-07515, in the U.S. District Court for the Southern District of New York.

This article is not legal advice. It is presented
for informational purposes only.