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Whistleblower lawsuit accuses Cigna of Medicare Advantage fraud

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A whistleblower lawsuit accuses Cigna of receiving “billions” in overpayments for its Medicare Advantage plans. The amended complaint, filed by the Department of Justice in the U.S. District Court for the Southern District of New York a year ago, was unsealed on Wednesday.

A former service provider for Cigna’s Medicare Advantage subsidiary alleged that the company sent providers to patients’ homes to conduct a health assessment, which was then improperly submitted to the Centers for Medicare and Medicaid Services for risk adjustment. The whistleblower was a former officer for Texas Health Management, a now-defunct company that worked with Cigna-Healthspring between 2012 and 2017.

Cigna acquired HealthSpring in 2012, and currently offers Medicare Advantage plans in 17 states under this brand.

Commercial insurers who offer Medicare Advantage plans receive a monthly capitated rate from CMS for each of their covered members, which they use to cover the cost of care. For older and sicker patients — who have higher risk scores — they receive a higher rate.

A patient’s risk score is based on diagnoses assigned to the patient in the prior year. To be submitted, a patient must have had a face-to-face encounter with a provider, and the patient must be cared for or assessed.

According to the plaintiff, Cigna ran an assessment program that sent nurses and nurse-practitioners to patients’ homes, where they were expected to see 35 patients per week and generate 20 or more diagnoses per visit. They were reportedly not allowed to provide care, prescribe medications or make referrals to specialists.

The complaint described the program as “…a  data-gathering exercise used to improperly record lucrative diagnoses to fraudulently raise risk cores and increase payments from CMS.”

According to court documents, Cigna-HealthSpring used analytics to sort members into different priority categories based on their medical histories. The company also reportedly sought to recruit primary care physicians to complete the assessments, at one point offering a $150 bonus per completed exam to provider who performed a certain volume of assessments each year

The Department of Justice decided not to intervene in the case in February. Specifically, the government declined to claim that Cigna violated the False Claims Act by conducting nurse home visits that did not involve providing medical treatment.

Cigna did not respond to requests for comment at the time of publication.

This isn’t the first time a Medicare Advantage plan has come under scrutiny for payments.

Last year, the Office of Inspector General reviewed “billions” in estimated Medicare Advantage payments that raised concerns. Looking at 2016 encounter data, the OIG found that Medicare Advantage Organizations almost always used chart reviews to add diagnoses, and that diagnoses reported only on chart reviews — without any service records — resulted in roughly $6.7 billion in risk-adjusted payments for 2017.

Of that, an estimated $2.7 billion in payments were based on diagnoses that did not link to a specific service provided to the member.

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Cigna rolls out teledentistry tool as practices struggle during pandemic

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As with routine check-ups, most dental appointments have been put on hold to prevent exposure to Covid-19 and save much-needed protective equipment. The vast majority of dental practices, at 79%, have closed except for emergency procedures. Another 18% of dental practices have closed completely, according to the American Dental Association.

To make up for their losses, some practices have begun offering teledentistry. Health insurer Cigna also struck a recent partnership with the TeleDentists, a company that offers virtual dental consults.

The idea of teledentistry can be a bit puzzling. What can dentists treat over a screen? According to Cigna, the video consults can be used to diagnose causes of pain and swelling, and answer questions about a chipped tooth or a loose crown. If needed, the dentist could prescribe antibiotics or non-narcotic pain relievers.

Cigna had originally planned to roll out the dental virtual care service in the third quarter, but fast-tracked the program in light of the pandemic. Cigna plans to offer the service for free until May 31. The TeleDentists has more than 300 dentists in its network.

While teledentistry and emergency appointments can help fill some of the gaps, they can’t sustain dental practices for long. Most dental practices are seeing less than 5% of the volume that they would typically see, according to the ADA.

Of the 6,441 dentists that were polled on April 6, just 11% said their practices were still fully paying staff. 45% of practices were partially paying staff, and 44% were not paying any staff, a sharp drop from just two weeks ago.

The number of dental practices that are paying their staff has decreased sharply in two weeks, according to the American Dental Association

“Short-term financial relief from the Coronavirus Aid, Relief, and Economic Security Act, dental insurers and other groups as well as the enhanced use of teledentistry could help ease financial shortfalls in the short term,” Marko Vujicic, chief economist and vice president of the ADA’s Health Policy Institute, said in a statement. “What is clear at this stage, however, is that the coming two to three months represent a critical juncture for the economic sustainability of many dental practices.”

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Cigna taps MDLive for behavioral telehealth services

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Health insurance giant Cigna will begin giving members access to online behavioral health services through MDLive starting in 2020. Cigna will offer the service in addition to Cigna Behavioral Health’s existing network of more than 18,000 virtual behavioral health providers. It will be available to the 14 million members enrolled in one of Cigna’s employer-sponsored plans.

“Access to virtual behavioral care is critical,” said Eva Borden, senior managing director of behavioral and medical solutions for Cigna. “When we first embarked on bringing forth virtual care, we started with our own provider network. It was through doing that that we saw there was a need.”

Cigna members will be able to schedule online appointments and access care through a video channel. They will have access to everything from cognitive behavioral therapy to prescriptions, as the platform hosts licensed counselors, psychologists and psychiatrists.

Borden said she hoped the new service would help create better access to mental healthcare for patients, particularly those that face barriers in schedules, geography or accessibility. Roughly 20 percent of people in the U.S. have a mental health condition, but only a third of them seek care.

For Borden, who lives in rural Iowa, driving into the city for an appointment would take a total of three hours out of her workday. Through a telehealth service, she could make that same appointment over her lunch break.

“Driving that distance would be a complete barrier to care,” she said.

The new partnership will be an extension of Cigna’s existing work with MDLive. The two companies began working together in 2014, starting with MDLive’s virtual urgent care services.  Cigna is also an investor in MDLive; the payer recently led MDLive’s $50 million funding round in August of 2018.

Since Sunrise, Florida-based MDLive was founded a decade ago, the company has accumulated 35 million members for its urgent care, behavioral health and dermatology services. With the expansion of its partnership with Cigna, the telehealth company will add another 12.5 million members, MDLive CEO Rich Berner said.

“We’re helping them get access to very sorely needed services,” he said.

MDLive’s medical services still account for the company’s largest business segment, but the company’s newer behavioral health services are growing quickly. Berner said the company started building out the behavioral health aspect of its platform a little over three years ago, and it is now the fastest-growing segment.

“Whenever we look at new services, we focus on what problem are we trying to solve. Access is a huge issue. Convenience is a growing demand by consumers. The thinking was we could solve those problems by bringing it online,” Berner said. “The health care industry as a whole is trying to shift from reactive care to proactive health management. Many people with chronic conditions need therapy and don’t get access to it for reasons we talked about.”

Borden said she thinks MDLive’s solutions would be a “critical part of our foundation” in solving the problem of access to behavioral health services. But there‘s still plenty of work ahead.

“It won’t solve it all at once,” she added.

 

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Report: Cigna may look to divest group benefits insurance business

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Major health insurer Cigna is mulling a sale of its group benefits business in a deal that could be valued at up to $6 billion, according to a report from Reuters.

Selling off the business division, which includes a range of benefit offerings including disability coverage, life insurance and accidental death and dismemberment coverage, would work to organize the company even more strongly on its central healthcare business.

Cigna’s sharpened focus on healthcare is evidenced by a number of recent moves, including, most notably its $54 billion acquisition of pharmacy benefits manager Express Scripts last year.

A major priority for the company as stated by CEO David Cordani in the company’s second quarter earnings call is “treating the whole person” by creating new health coaching and clinical products.

Reuters cited unnamed sources who said that the insurer has enlisted an investment bank to field offers for the division from suitors that could include insurers looking to boost up their own group benefits business.

The company didn’t completely shut down rumors instead saying it “continually review(s) opportunities to ensure we continue to deliver value to our customers and clients.”

According to the company’s recent earnings report, the group benefits division made $1.3 billion in revenue in the second quarter and covers 15.4 million people. The business division brought in $5.06 billion in revenue over 2018.

Cigna isn’t alone in seeking to unload ancillary business lines as it hones its focus on the healthcare space. Aetna – which was the subject of its own 2018 mega-merger with CVS Health – unloaded its U.S. group life and disability business to The Hartford for $1.45 billion in 2017.

Health insurance companies have come under increasing scrutiny by regulators in the wake of the growing M&A activity exemplified by the CVS-Aetna and Cigna-Express Scripts deal.

Politicians have also continued to beat up on health insurers as the drumbeat for a Medicare-For-All system or public option continues to get louder.

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Cigna and VA join forces to help veterans at risk of opioid misuse

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White pharmaceutical pills spilling from prescription bottle over American map

Health insurer Cigna and the Department of Veterans Affairs have partnered in an effort to aid veterans with chronic pain who are also at risk for opioid misuse.

By teaming up, the organizations seek to educate healthcare providers as well as veterans and their families about safe opioid use.

In a statement, Cigna president and CEO David Cordani noted that his organization plans to share its resources and practices to help veterans.

The VA and Cigna also intend to promote existing support resources like the Veterans Crisis Line and Cigna’s Veterans Support Line.

“This partnership is in line with VA’s priorities of transforming our business systems and supporting more robust partnerships with state and local communities,” VA Secretary Robert Wilkie said in a statement. “By partnering with Cigna, we have extended our reach to help improve the way healthcare providers approach opioid use and we demonstrate our commitment to place Veterans’ safety and well-being above all.”

The ultimate aim of the partnership, which was formalized in early March, is to improve opioid use-related patient-provider interactions and boost the delivery of care and health outcomes for veterans.

As the opioid epidemic rages on, other organizations are working to offer solutions to the problem.

At the Health 2.0 conference last fall, startups in the $50,000 Robert Wood Johnson Foundation Opioid Challenge pitched ideas on using tech to support substance abuse treatment. The winner of the competition was Boston-based Sober Grid, which created a platform to help users locate nearby treatment centers. It also offers telehealth capabilities that can connect patients to professional and peer counselors. The startup was founded back in 2015.

Additionally, Blue Shield of California launched a Narcotic Safety Initiative in 2015. Earlier this year, the results of that project showed a 56 percent reduction in overall opioid use among the payer’s members with chronic, non-cancer pain compared to 2014.

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