Aetna Inc. has agreed to pay $117,700,000 to settle allegations that it violated the False Claims Act by submitting or failing to withdraw inaccurate diagnosis codes for Medicare Advantage Plan enrollees, according to a Mar. 10 announcement by United States Attorney David Metcalf.
The settlement addresses concerns about the integrity of the Medicare Advantage program and the proper use of government funds intended for healthcare services for seniors and vulnerable citizens. The government alleges that Aetna's actions resulted in increased payments from Medicare by inflating patient diagnoses.
Under the Medicare Advantage Program, also known as Medicare Part C, private insurers receive fixed monthly payments from the Centers for Medicare & Medicaid Services (CMS) based on risk factors such as patient health status. The United States contends that Aetna submitted inaccurate diagnosis data to CMS, failed to correct these inaccuracies, and falsely certified their accuracy in writing. Most of the settlement—$106.2 million—resolves claims related to a chart review program in payment year 2015 where Aetna allegedly used medical record reviews both to seek additional payments and failed to remove unsupported diagnosis codes when overpayments were identified.
An additional $11.5 million resolves allegations that between 2018 and 2023, Aetna knowingly submitted or did not delete inaccurate morbid obesity diagnosis codes for individuals whose body mass index did not support such a diagnosis. This portion of the settlement relates to a whistleblower lawsuit filed under the False Claims Act provisions, with the whistleblower receiving $2,012,500 from the settlement.
"The government pays Medicare Advantage Organizations to facilitate vital healthcare to our seniors and other vulnerable citizens," said U.S. Attorney Metcalf. "When corporations or individuals threaten the Medicare Advantage program by diverting those limited government resources through fraud, waste, or abuse, we will continue to pursue all available remedies against them." Assistant Attorney General Brett A. Shumate added: "We will continue to hold accountable insurers that knowingly submit inaccurate or unsupported diagnoses to improperly inflate reimbursement." Acting Deputy Inspector General Scott J. Lampert stated: "Today’s settlement makes clear that no company is beyond accountability, no matter how large or well known. Those who seek to exploit Medicare Advantage should expect to be identified and held responsible..."
The investigation was handled by officials in Pennsylvania with assistance from HHS-OIG investigators and attorneys from multiple federal offices. The Department of Health and Human Services encourages tips about potential fraud at https://oig.hhs.gov/fraud/report-fraud/ or via phone at 800-HHS-TIPS (800-447-8477).
Officials emphasized that these are only allegations; there has been no determination of liability.
