DOJ cleared to force testimony from Anthem in Medicare Advantage fraud investigation

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Anthem must turn over information requested in a civil investigative demand focused on MA plans. (Matthew Hurst/CC BY-SA 2.0--bit.ly/2Q6zEPP)

A New York judge says Anthem must release testimony to federal prosecutors as part of a fraud investigation into the insurer’s Medicare Advantage plans.

The ruling follows an extended back-and-forth between the Department of Justice (DOJ) and Anthem over information requested as part of a civil investigative demand (CID) issued to the insurer in March. The feds requested in a court mandate that Anthem turn over specific testimony on how the company calculated risk adjustment data and Medicare Advantage diagnosis codes.

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

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Investigators are zeroing in on the company’s retrospective chart review that brought in more than $215 million over two years.

On Tuesday, U.S Magistrate Judge Kevin Nathaniel Fox said (PDF) that the government's petition should be granted, and a date set for witness testimony.

The judge shot down Anthem’s argument that it offered to meet with DOJ investigators in person on nearly a dozen occasions, noting that Anthem’s attorneys had previously viewed written correspondence as satisfactory to conferring about CID topics requested by the government. The court also noted that the scope of the request was reasonable and necessary to the overall investigation, and that Anthem failed to show it would be overly burdensome.

Anthem is the latest insurer to come under fire for Medicare Advantage coding issues, and court filings indicate prosecutors may be close to filing a complaint.

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

UnitedHealth has beat back one whistleblower lawsuit alleging it fudged risk scores in order to increase MA reimbursement, which is based on member diagnoses. But the insurer is still entwined in a second lawsuit joined by federal prosecutors.

Meanwhile, Aetna, Centene, Cigna and Humana have all received CIDs related to MA risk adjustment practices, according to financial disclosures.

At the same time, a September court decision provided a big win for MA insurers by striking down a 2014 federal rule that required plans to report and return overpayments associated with any incorrect diagnosis codes. The Department of Health and Human Services filed an appeal earlier this month.

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