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US Justice Department Sues Anthem for Allegedly Submitting False Diagnosis Data to CMS

NEW YORK – The US Attorney for the Southern District of New York announced Friday the filing of a civil fraud lawsuit against insurer Anthem for allegedly falsely certifying diagnosis data submitted to the Centers for Medicare and Medicaid Services. 

Under Medicare Part C, also known as Medicare Advantage, Anthem is required to submit diagnosis data to CMS, which the agency then uses to calculate a risk score for each beneficiary that determines the payment Anthem receives from CMS for covering that patient.

According to the lawsuit, Anthem allegedly used a chart review program to identify all diagnosis codes supported by the medical records of beneficiaries and submitted those codes to CMS without verifying whether those code were correct. Deleting the codes would have reduced the additional revenue the chart review program brought in, the lawsuit said. "Anthem treated its chart review program solely as a tool for revenue enhancement and viewed it as Anthem's 'cash cow,'" the attorney's office said in a statement. 

The federal government is seeking damages, fees, and penalties in amounts to be determined at trial. 

The insurer also allegedly falsely certified that its data submissions were accurate and agreed to research and correct data discrepancies, which the suit alleges it did not do.

In response to the suit, Anthem said in an email it is "confident that our health plans and associates have complied with Medicare Advantage regulations, including those set forth by the Centers for Medicare & Medicaid Services, and we intend to vigorously defend our Medicare risk adjustment practices." The payor added "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." 

"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," the insurer said. "We think the agency should update regulations if it would like to change how it reimburses plans for services delivered."