The Department of Justice sued Anthem March 26, alleging the health insurance company submitted inaccurate diagnosis codes to the federal government to get higher reimbursement.
The lawsuit, pending in U.S. District Court for the Southern District of New York, alleges Anthem submitted the inaccurate codes from 2014 through early 2018 to obtain higher reimbursement for its Medicare Part C, or Medicare Advantage, plans.
"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 for hundreds of thousands of Medicare beneficiaries covered by the Medicare Part C plans offered by Anthem," states the complaint. "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 Justice Department alleges that Anthem repeatedly attested to CMS that its risk adjustment diagnosis data submissions were accurate and complete.
"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," states the complaint. "Anthem's actual practices … were in direct contravention of its promises and attestations to CMS."
In a statement to Axios, which was the first to report on the lawsuit, Anthem said it is "confident that our health plans and associates have complied with Medicare Advantage regulations." The insurer, which intends to "vigorously defend" its Medicare risk adjustment practices, said "the government is trying to hold Anthem and other Medicare Advantage plans to payment standards that CMS does not apply to original Medicare, and those inconsistent standards violate the law."