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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

9 mins ago - World

G7 leaders agree to call out China's “nonmarket policies and human rights abuses"

President Biden and first lady Jill Biden arrive at Cornwall Airport Newquay to give a press conference on the final day of the G7 summit on June 13, 2021. Photo: Brendan SMIALOWSKI / AFP via Getty Images

Group of Seven leaders on Sunday announced they have agreed work together to challenge China’s “non-market economic practices” and to press Beijing to respect human rights in Hong Kong and Xinjiang.

Why it matters: President Biden went into the summit hoping to present a united front against Beijing.

Study: Key Antarctic ice shelf is speeding up its collapse

Pine Island Glacier calves several new icebergs on Feb. 11, 2020, as seen via satellite. Photo: NASA Earth Observatory

The Pine Island Glacier on the West Antarctic Ice Sheet is responsible for more than a quarter of Antarctica's contribution to global sea level rise over the past decades. Now, a new study shows it is more vulnerable to rapid melting than thought, because climate change is weakening its natural braking system.

Why it matters: At stake is the future of a glacier containing about 160 trillion tons of ice, which if it were all to melt into the ocean would cause about 1.6 feet of global sea level rise.

Felix Salmon, author of Capital
4 hours ago - Economy & Business

Workers are taking power back

Illustration: Aïda Amer/Axios

American workers have been losing power since 1980 — but now the tables are turning.

Why it matters: The 2010s gave us the gig economy and left millions of workers stranded seemingly forever on the precipice of financial ruin. The 2020s could be the decade when workers seize back the reins of power.