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Anthem Is Sued By US For Fraud on Medicare and Medicaid In Filing Inner City Press Found

By Matthew Russell Lee, Exclusive Patreon
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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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