A lawsuit filed by the Department of Justice against Anthem accuses the insurer of collection million of dollars by failing to delete inaccurate diagnosis codes for Medicare Advantage patients. The suit was filed on Friday by Geoffrey Berman, United States Attorney for the Southern District of New York.

The case alleges that Anthem falsely certified the accuracy of the diagnostic data it sent to the Centers for Medicare and Medicaid Services, causing CMS to calculate risk-adjustment payments to the insurer based on inflated diagnosis information. For example, Anthem submitted an ICD-9 diagnosis code for active lung cancer for one patient, but its chart review program did not substantiate the diagnosis, according to court documents.

Anthem implemented a retrospective chart review program using a vendor called Medi-Connect, according to the lawsuit. The insurer reportedly paid Medi-Connect to connect medical records from healthcare providers and review them to identify diagnostic codes supported by the medical records.

According to court documents, from 2014 to 2018, Anthem allegedly used the chart review program to find additional codes to submit to CMS while failing to identify and delete inaccurate codes. The chart review program brought in more than $100 million in revenue per year for Anthem, according to the complaint.

“The integrity of Medicare’s payment system is critical to our healthcare,” Berman said in a news release. “This office is dedicated to vigorously using all of the legal tools available, including the False Claims Act, to ensure the integrity of Medicare payments.  The case against Anthem today is an illustration of that commitment.”

Anthem said it was confident its health plans complied with regulations, and that it would vigorously defend its risk adjustment practices.

“This litigation is the latest in a series of investigations on Medicare Advantage plans. The government is trying to hold Anthem and other Medicare Advantage plans to payment standards that CMS does not apply to original Medicare, and those inconsistent standards violate the law,” the company wrote in an emailed statement. “The suit is another in a pattern that attempts to hold Anthem and other plans to a standard on risk adjustment practices, without providing clear guidance. Where regulations have not been clear, Anthem has been transparent with CMS about its business practices and good faith efforts to comply with program rules.”

Photo credit: zimmytws, Getty Images



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