DOJ sues Anthem over Medicare Advantage fraud claims

Anthem faces a federal lawsuit for submitting inaccurate diagnostic data to get a higher Medicare reimbursement.

The U.S. Attorney for the Southern District of New York said in the lawsuit filed late Thursday that Anthem failed to find and delete inaccurate diagnosis codes from 2014 to early 2018 through its “chart review program,”

“By ignoring its duty to delete thousands of inaccurate diagnoses, Anthem unlawfully obtained and retained from [Centers for Medicare & Medicaid Services] millions of dollars in payments under the risk adjustment payment system for Medicare Part C,” the lawsuit (PDF) said.

Anthem knew that because the diagnostic codes affected payment directly then it had to ensure that its data submissions were “accurate and truthful.”

The lawsuit also said the insurer had attest to CMS that its risk adjustment diagnoses were truthful.

“As Anthem knew, the promises and attestations it made to CMS placed on Anthem an obligation to make good faith efforts to delete inaccurate diagnosis codes,” the lawsuit added.

Anthem responded that it is “confident” its health plans and associates complied with federal regulations, Axios reported.

“We intend to vigorously defend our Medicare risk adjustment practices,” the insurer said in a statement. “This suit is another pattern that attempts to hold Anthem and other plans to a standard on risk adjustment practices, without providing clear guidance.”