Anthem pushes back on Medicare Advantage fraud probe, cites 11 attempts to meet with DOJ

Anthem asked the court to block the DOJ's request to compel testimony, citing repeated attempts to discuss the request. (Matthew Hurst/CC BY-SA 2.0)

Anthem is fighting off an attempt by the Department of Justice to compel evidence tied to a Medicare Advantage fraud investigation, citing repeated attempts to consult with federal prosecutors about the scope of their request.

Anthem attempted to meet with federal prosecutors on 11 separate occasions to discuss a civil investigative demand (CID) issued in April, according to documents filed on Tuesday with the U.S. District Court for the Southern District of New York. At issue is testimony about the processes and procedures the insurer had in place to ensure that member diagnosis codes were appropriately submitted to the Centers for Medicare & Medicaid Services.

Diagnosis codes are used by the agency to determine the level of retirement for each member based on their overall health. Last month, DOJ prosecutors took Anthem to court to force the insurer to turn over testimony related to an ongoing investigation around the insurer’s retrospective chart review and whether the company knew it submitted incorrect codes.


Employer-Based Insurance: Top Priorities for 2019

Join Blue Health Intelligence (BHI) and Midwest Business Group on Health (MBGH) to hear how key descriptive, predictive and prescriptive analytics capabilities can drive new cost and quality insights for health plans, employers and benefit consultants.

But Anthem told the court the request goes well beyond the scope of the investigation and “poses a massive and unreasonable burden” since the company submits more than 12 million diagnosis codes each year. Anthem also says federal prosecutors have repeatedly rebuffed nearly a dozen attempts to discuss the request.

RELATED: DOJ takes Anthem to court over refusal to comply with Medicare Advantage fraud investigation

“Anthem remains baffled why the government has refused nearly a dozen requests for a simple call or meeting to discuss these specific deposition topics,” the insurer wrote in a court filing (PDF) this week.

Meanwhile, a letter (PDF) sent from the DOJ to Anthem on August 9 references a third CID issued on June 12. The CIDs asked for testimony from seven Anthem employees and the results of five electronic searches.

Prosecutors asked for the materials by Sept. 10 and Sept. 27, adding that it intends to file another court petition if Anthem refuses to comply.

The document requests are closely tied to the DOJ’s litigation with UnitedHealthcare, specifically whether Anthem knowingly submitted inaccurate data to obtain risk adjustment payments. Previous court filings show Anthem brought in $214 million in risk adjustment payments following a retrospective chart review, a 5-1 return on investment.