Indianapolis-based Elevance Health, formerly Anthem, Inc., will face a federal lawsuit. Farah Yousry / WFYI
Indianapolis-based health insurance giant Elevance Health, formerly Anthem, Inc., will face a federal lawsuit alleging it pocketed at least tens of millions of dollars by submitting inaccurate claims to the Centers for Medicaid & Medicare Services of the United States.
The original lawsuit, filed by the US Department of Justice in March 2020, alleges the company failed to verify diagnostic codes it submitted for reimbursement between early 2014 and 2018 for its Medicare Advantage plans for seniors. . These plans are managed by private insurers like Elevance Health who contract with CMS. About 28.7 million people — nearly half of all eligible Medicare beneficiaries — are covered by these plans.
Earlier this week, a US District Judge in Manhattan ruled that the company had failed to prove the lawsuit lacked materiality. Judge Andrew Carter said the financial costs to the government were “substantial” and not “merely administrative” –– amounting to more than $100 million.
In a statement to WFYI, Elevance Health said it was complying with federal regulations.
“We are confident that our health plans and associates have complied with Medicare Advantage regulations, including those established by the Centers for Medicare & Medicaid Services,” the statement said.
Elevance said the company operates in “good faith” and that CMS should update the regulations if the agency wants to “change the way it reimburses Medicare Advantage plans for health services.”
But the lawsuit alleges that when Elevance reviewed the diagnostic trouble codes it had submitted to CMS and found some to be invalid, the company “made no effort to verify or remove those codes.” In his decision letter dated September 30, Justice Carter said the plaintiff alleges the company was aware of CMS’s diagnostic data submission requirements.
This story comes from a reporting collaboration that includes Indianapolis Recorder and Side Effects Public Media, a public health information initiative based at WFYI. Contact Farah at [email protected]. Follow on Twitter: @Farah_Yousrym.
