News: DOJ sues Anthem over Medicare Advantage fraud claims

Anthem is currently facing a False Claims Act lawsuit from the Department of Justice (DOJ) for submitting inaccurate diagnosis codes to get a higher Medicare reimbursement. The lawsuit says 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 [CMS] millions of dollars in payments under the risk adjustment payment system for Medicare Part C,” the lawsuit said.

The lawsuit alleges that in practice, “Anthem treated chart review solely as a ‘revenue enhancement program’ and chose not to use chart review results to verify the accuracy of previously-submitted diagnosis codes based on provider claims.”

When instructing their chart review contractors on how to review and code records, Anthem instructed them to “cold code” the charts (code without looking at the originally submitted claims) and then add any additional revenue-generating codes to the claim submitted to CMS. By contrast, according to the lawsuit, Anthem did not have a process in place for adding non-revenue-generating codes or removing any erroneous codes from previously submitted claims.

Additionally, according to their internal records, the lawsuit says that Anthem classified chart review as a “revenue enhancement program” and internal analysts constantly looked for ways to improve the chart review program’s return on investment.

Anthem responded that it is “confident” it complied with federal regulations.

“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.”

Editor’s note: To read the full lawsuit, click here. To read about other DOJ audit activity, click here. To read FierceHealthcare’s coverage of this story, click here. To learn more about CDI professionals’ role in risk adjustment coding and documentation, join us for a webinar on April 9.