On March 26, 2020, the Manhattan U.S. Attorney’s Office filed suit against Anthem, Inc. for violations of the False Claims Act. The complaint alleges that between 2014–2018, Anthem submitted inaccurate diagnosis codes to CMS for hundreds of thousands of Medicare beneficiaries covered by Medicare Part C (Medicare Advantage) plans. As a result, the government argues, Anthem unlawfully obtained and retained millions of dollars in payments under the risk adjustment payment system, which CMS uses to calculate payments to Medicare Advantage organizations.

The government’s overarching allegation against Anthem is that it reviewed the medical charts it received from providers “only to submit additional diagnosis codes to CMS while turning a blind eye to negative results where chart reviews could not substantiate the diagnosis codes that Anthem had previously submitted to CMS.” (emphasis added) In other words, “Anthem made ‘revenue enhancement’ the sole purpose of its chart review program,” according to the government. The government provides several specific examples of alleged fraud in the complaint. In one example, the government alleges that Anthem coded a beneficiary as having active lung cancer. Despite this coding, “Anthem’s chart review program did not substantiate the active lung cancer diagnosis.” The government then contends that, for this same beneficiary, Anthem added three additional superfluous codes, which resulted in an overpayment of $7,081.

Earlier this year, DOJ singled out these types of risk adjustment cases as a top priority for False Claims Act enforcement in 2020. The case against Anthem further confirms the government’s commitment. The complaint is available here.