Whistleblower allegations results in real change for patients.

Cigna is paying $172 million after defrauding the United States for years. But that’s not the story here. Cigna is a $90 billion publicly traded healthcare insurer. No one is surprised that it’s engaged in light fraud from time to time. This fine barely makes a dent.

The story here is the whistleblower, Robert Cutler. Robert was not even a Cigna employee. He was a part owner of a Cigna vendor. He didn’t even have visibility into three of the four types of fraudulent activity that Cigna was involved in. In all likelihood, Robert faced retaliation for his actions–note that the press release characterizes him as a former part owner. For his courageous and righteous stand, Cigna will have to implement a slew of accountability and auditing provisions including requiring certifications about compliance measures from Cigna’s board! That’s a real impact. And, for his trouble, Robert will collect a cool $8.1 million for shining a light on the fraud that he saw occurring.

From the press release:

As a result of Robert’s efforts, the United States uncovered four different types of fraudulent activity that Cigna was involved in.

First, submitted inaccurate and untruthful patient diagnosis data to CMS in order to inflate the payments it received from CMS, failed to withdraw the inaccurate and untruthful diagnosis data and repay CMS, and falsely certified in writing to CMS that the data was accurate and truthful.

Second, it’s chart reviews did not substantiate some diagnosis codes that were reported by providers and previously submitted by Cigna to CMS. Cigna did not delete or withdraw these inaccurate and untruthful diagnosis codes, however, which would have required Cigna to reimburse CMS. Cigna used the results of its chart reviews to identify instances where it could seek additional payments from CMS, while improperly failing to use those same results when they provided information about instances where Cigna was overpaid.

Third, Cigna reported diagnosis codes to CMS that were based solely on forms completed by vendors retained and paid by Cigna to conduct in-home assessments of plan members. But those vendors did not perform or order the diagnostic testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported, and were in many cases prohibited by Cigna from providing any treatment during the home visits for the medical conditions they purportedly found. Nevertheless, Cigna submitted these diagnoses to CMS to claim increased payments, and falsely certified each year that the diagnosis data it submitted was “accurate, complete, and truthful.”

Fourth, Cigna knowingly submitted and/or failed to delete or withdraw inaccurate and untruthful diagnosis codes for morbid obesity to increase the payments it received from CMS for numerous beneficiaries enrolled in its MA plans. It submitted or failed to delete inaccurate and untruthful diagnosis codes for morbid obesity for individuals lacking a BMI of 35 or above, and these codes increased the payments made by CMS.

Pretty amazing–Robert only knew about one of these, reported it, started an investigation which revealed several more types of fraudulent activity, got paid, and will be creating lasting change.

Cigna entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). The CIA requires that Cigna implement numerous accountability and auditing provisions. On an annual basis, top executives and members of the Board of Directors must make certifications about Cigna’s compliance measures, Cigna must conduct annual risk assessments and other monitoring, and an independent review organization will conduct multi-faceted audits focused on risk adjustment data.