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Anthem's headquarters in Indianapolis. Photo: Aaron P. Bernstein/Getty Images

The Department of Justice has sued Anthem, alleging that the health insurance company knowingly submitted inaccurate medical codes to the federal government from 2014 to 2018 as a way to get higher payments for its Medicare Advantage plans and turned "a blind eye" to coding problems.

Why it matters: This is one of the largest Medicare Advantage fraud lawsuits to date, and federal prosecutors believe they have more than enough to evidence to claim that Anthem bilked millions of dollars from taxpayers.

Background: DOJ has been probing the "risk adjustment" practices of all the major Medicare Advantage insurers for years, but hadn't pulled the trigger on a lawsuit against a major player.

  • Risk adjustment is the process by which Medicare Advantage companies assign scores to their members based on the health conditions they have. Patients who have higher risk scores lead to higher payments from the federal government to the companies that insure them.
  • Insurers are required to review patients' medical charts to verify the health conditions, and if insurers find any inaccurate diagnoses, they have to be deleted — which also would require the companies to pay back money to the federal government.

The Department of Justice is alleging that Anthem reviewed medical records, but only focused on finding "all possible new revenue-generating codes" while purposefully ignoring all erroneous diagnoses.

  • For example, according to the DOJ's lawsuit, Anthem coded one member in 2015 as having active lung cancer.
  • "Anthem’s chart review program did not substantiate the active lung cancer diagnosis," the DOJ alleges. Instead of deleting that diagnosis, Anthem allegedly added another three codes — leading to a $7,000 overpayment just for that member that year.

The other side: Anthem said in a statement that it intends "to vigorously defend our Medicare risk adjustment practices" and that "the government is trying to hold Anthem and other Medicare Advantage plans to payment standards that CMS does not apply to original Medicare."

The big picture: Medicare Advantage continues to enroll seniors and people with disabilities at high rates, even as more allegations of fraud come out against the insurers that run the program.

Read the lawsuit.

Go deeper

Dave Lawler, author of World
3 mins ago - World

Mixed response in Europe to Biden's vaccine patents bombshell

Illustration: Aïda Amer/Axios

The Biden administration surprised the world last night by coming out in favor of waiving patents for coronavirus vaccines — but Europe is divided on the issue.

What they're saying: European Commission President Ursula Von Der Leyen said Brussels would be willing to discuss it; French President Emmanuel Macron said he backed the U.S. position, but a German government spokesman said the proposal would cause "severe complications" for vaccine production.

Updated 15 mins ago - Politics & Policy

Coronavirus dashboard

Illustration: Rae Cook/Axios

  1. Health: CDC expects new COVID surge starting this month — Coronavirus cases hit a seven-month low
  2. Politics: Federal judge overturns CDC's eviction moratorium — Why Biden's latest vaccine goal is his hardest yet.
  3. Vaccines: Moderna says its COVID booster shot shows promise against variants — U.S. will support waiving vaccine patents — Education secretary: All schools expected to be fully in-person this fall
  4. Economy: U.S. may have added more than 2 million jobs in April — A surge in youth unemployment.
  5. World: True COVID-19 death toll is double the official numbers, study finds — Countries testing J&J vaccine doses after contamination at Baltimore plant — Germany opposes Biden's support for waiving vaccine patents
  6. Variant tracker: Where different strains are spreading.
Dave Lawler, author of World
26 mins ago - World

True COVID-19 death toll is double the official numbers, study finds

Expand chart
Data: IHME; Chart: Will Chase/Axios

There have been twice as many deaths from COVID-19 around the world as have been reported, according to the University of Washington's Institute for Health Metrics and Evaluation (IHME), which analyzed excess mortality and other factors.

The big picture: The U.S. has undercounted by over 300,000 deaths, while the death tolls in India and Mexico — second and third on the list, respectively — are nearly three times the official numbers, according to the analysis.