, one of the largest private insurers in the US, operates multiple MA plans across the country. Many of these MA plans take part in a 360 comprehensive health assessment, which is essentially a Cigna-created physical to assess the wellness of MA plan members.
For those receiving home care services, Cigna contracted vendor healthcare providers (VHCPs) to send staff like nurses and physician assistants to help complete the 360 form.
Typically, the VHCPs fill out the 360 form, and Cigna’s teams identify corresponding diagnosis codes using the ICD-10 medical classification list. These diagnosis codes can be used to determine risk scores which can be submitted to CMS for determining payment rates to the insurer.
Yet, the Justice Department, after being tipped off by a whistleblower in Cigna, alleges that Cigna pressured VHCPs to make home care patients appear sicker than they actually were.
VHCPs were instructed to prioritize capturing diagnoses and discouraged actual treatment of what these supposed conditions were. That’s not just the department… it’s from an internal Cigna document:
“[t]the primary goal of a 360 visit is administrative code capture and not chronic care or acute care management.”
The lawsuit further details that thousands of 360 home visit programs featured diagnoses where only the VHCP reported it without another doctor seeing the patient for the same condition and without necessary diagnostic equipment.
One case highlights a VHCP diagnosing a patient with congestive heart failure when the same document noted the patient’s heart to seem “normal”.
Internally, Cigna also tracked the volume of diagnoses these VHCPs sent back, and for those providing insufficient diagnoses, Cigna required them to complete “performance improvement plans”.
during the first nine months of 2014, one vendor’s 6,658 in-home visits resulted in more than an additional $14 million in Medicare payments, which dwarfed the approximately $2.13 million that CIGNA paid to the vendor