Eden Nelson
Originally published January 2021 Particularly given the need to maintain ongoing working
relationships with payors who process health care providers’
claims, providers who believe that they are under investigation or
have active disputes with commercial insurers should immediately
contact counsel experienced with such disputes. The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
According to Cigna, the defendants’ waiver of patient
copayments, deductibles, and coinsurance obligations was a
subterfuge designed to avoid Cigna’s detection of the false
claims. Cigna alleged the claims were also false because, among
other things: (i) they contained altered medical diagnosis codes so
that claims would be reimbursed at higher rates; (ii) certain
medical records were inaccurate; or (iii) they were for services
that were never rendered. When defendants failed to adequately
respond to the complaint, the federal court entered its
judgment. On January 13, 2021, a federal district court in Dallas, Texas,
entered judgment against two health care providers and their
managers, awarding $5.8 million to Cigna Health and Life Insurance
Company and its affiliates. According to Cigna’s complaint, the
company’s special investigation unit had investigated the
defendants for years, including unannounced onsite visits. Cigna
then allegedly discovered that the defendants had submitted
fraudulent claims to Cigna.
Suggestion For You:
The Cigna case is only the most recent in a line of
cases brought by aggressive commercial insurers asserting
allegations that health care providers have submitted false or
fraudulent claims for payment. Such cases frequently have included
legal theories very similar to those asserted by the government in
cases brought under the federal False Claims Act (31 U.S.C. 3729,
et seq.) and its state analogues. For example, Aetna,
UnitedHealthcare, and Blue Cross & Blue Shield of Mississippi
have all recently sued several health care providers alleging the
submission of false claims for laboratory services. Complaints have
asserted causes of action under civil RICO and common law fraud,
among others, and sought millions of dollars in treble damages and
attorneys’ fees. Health care providers have seen an increase in litigation and
disputes with commercial payors.
The Biden Administration is expected to devote significant resources to investigating fraud and abuse in the health care industry. Not only will the Biden Administration likely continue… Source WilmerHale
Biden Health Care Enforcement Priorities POPULAR ARTICLES ON: Food, Drugs, Healthcare, Life Sciences from United States
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