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 from 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 case highlights ongoing efforts by federal authorities to combat fraud in government healthcare programs.
Under the Medicare Advantage Program, also known as Medicare Part C, private insurance companies receive fixed monthly payments from the Centers for Medicare & Medicaid Services (CMS) based on risk factors related to beneficiaries’ health status. The United States alleges that Aetna submitted inaccurate patient diagnosis data to CMS in order to increase its payments and failed to correct or withdraw these inaccuracies, while falsely certifying their accuracy.
For payment year 2015, Aetna operated a chart review program where medical records were reviewed and additional diagnosis codes were submitted to CMS for extra payments. According to federal authorities, some of these codes were not substantiated by provider documentation but were not withdrawn by Aetna, resulting in overpayments that were not reimbursed. Of the total settlement amount, $106.2 million resolves these specific allegations.
An additional $11.5 million addresses claims that between 2018 and 2023, Aetna knowingly submitted or failed to delete inaccurate morbid obesity diagnosis codes when patients’ recorded body mass index did not support such diagnoses. This portion of the settlement resolves a whistleblower lawsuit filed under the False Claims Act’s provisions allowing private parties to sue on behalf of the government; the whistleblower will receive over $2 million from this share.
“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 said: “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 divisions within the Department of Justice.
Federal authorities encourage anyone with information about potential fraud involving government healthcare programs like Medicare Advantage to report tips at https://oig.hhs.gov/fraud/report-fraud/ or call 800-HHS-TIPS (800-447-8477). The claims resolved are allegations only; there has been no determination of liability.
