DOJ sues Anthem over Medicare Advantage fraud

March 30, 2020

The Department of Justice sued Anthem Blue Cross Blue Shield on Thursday for Medicare fraud after Anthem submitted inaccurate medical codes to receive higher Medicare reimbursement.


The lawsuit alleges that Anthem violated the False Claims Act when it deliberately ignored and submitted coding mistakes from 2014 to 2018. Federal prosecutors claim these coding errors yielded Anthem billions of taxpayer dollars.


The complaint highlights examples of fraud, including an instance from 2015 where Anthem coded a patient member as having active lung cancer. Despite this coding, “Anthem’s chart review program did not substantiate the active lung cancer diagnosis.” For this same member, the complaint alleges Anthem added three additional superfluous codes, which yielded over $7,000 in overpayment.


“[T]he government is trying to hold Anthem and other Medicare Advantage plans to payment standards that CMS does not apply to original Medicare,” Anthem said in a statement. “The agency should update regulations if it would like to change how it reimburses plans for services delivered.”





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