| Anthem Is Sued By US For
Fraud on Medicare and Medicaid In Filing Inner
City Press Found
By Matthew
Russell Lee, Exclusive
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SDNY COURTHOUSE,
March 26 -- The US has sued
Anthem, Inc. for fraud, in a
filing found
by Inner City Press past 8 pm
on March 26 on the docket of
the U.S. District Court for
the Southern District of New
York. From the complaint, not
yet assigned to any SDNY
judge: "This is a civil fraud
action brought by the
Government against defendant
Anthem, Inc. (“Anthem”) to
recover treble damages
sustained by, and civil
penalties and restitution
owed to, the Government
as result of Anthem’s
violations of the False Claims
Act (“FCA”), 31 U.S.C. §
3729 et seq.
As set forth
below, Anthem knowingly
disregarded its duty to ensure
the accuracy of the risk
adjustment diagnosis data that
it submitted to the Centers
for Medicare and
Medicaid Services
(“CMS”) for hundreds of
thousands of Medicare
beneficiaries covered by the
Medicare Part C plans
operated by Anthem. 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. Case As
a Medicare Advantage
Organization (“MAO”), Anthem
was responsible for covering
the cost of services rendered
by healthcare providers like
hospitals and doctors’
offices for the Medicare
beneficiaries enrolled in
Anthem’s Part C plans.
Anthem, in turn,
received monthly
capitated payments from CMS
for providing such
coverage. See infra ¶¶
21-39.
3. Anthem
understood that CMS calculated
the payments to Anthem
pursuant to a risk adjustment
system, under which the
amounts of those payments were
based directly on the
number and the severity of the
diagnosis data — in the form
of ICD diagnosis codes —
that Anthem submitted to
CMS. See infra ¶¶ 27-44.
In most cases,
Anthem submitted the
diagnosis codes reported
by providers in the claims and
data that the providers
submitted to Anthem to
seek payments for treating
Medicare beneficiaries
enrolled in Anthem’s Part C
plans. 4. Anthem knew that,
because the diagnosis codes it
submitted to CMS affected
payment directly, it had an
obligation to ensure that its
data submissions were accurate
and truthful, including
by complying with the ICD
coding guidelines adopted by
CMS regulations.
See infra ¶¶ 45-50.
Indeed, Anthem
expressly promised CMS that it
would “research and
correct” any “discrepancies”
in its “risk adjustment data”
submissions and that it would
comply with CMS’s
regulatory and contractual
requirement that diagnosis
codes for risk
adjustment purposes must
be substantiated by
beneficiaries’ medical
records. See infra ¶¶
79-82.
In
addition, Anthem repeatedly
attested to CMS that its risk
adjustment diagnosis data
submissions were
“accurate, complete, and
truthful” according to its
“best knowledge, information
and belief.” See
infra ¶¶ 83-90. 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." We'll have
more on this. The case is US v
Anthem, 20-cv-2593 (UA).
***
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