Aetna agrees to $117.7M settlement to resolve False Claims Act allegations

WASHINGTON – Aetna has agreed to pay $117.7 million to resolve allegations that it violated the False Claims Act by submitting or failing to withdraw inaccurate and untruthful diagnosis codes for its Medicare Advantage plan enrollees to increase its payments to Medicare, according to U.S. Department of Justice.

The government alleges that Aetna:

• Submitted inaccurate and untruthful patient diagnosis data to CMS to inflate the risk adjustment payments it received from CMS;
• Failed to withdraw the inaccurate and untruthful diagnosis data and repay CMS; and
• Falsely certified in writing to CMS that the data was accurate and truthful.

“The government pays private insurers over $530 billion each year to care for Americans enrolled in Medicare Advantage,” said Assistant Attorney General Brett A. Shumate of the Justice Department's Civil Division. “We will continue to hold accountable insurers that knowingly submit inaccurate or unsupported diagnoses to improperly inflate reimbursement.”

According to the government:

For payment year 2015, Aetna operated a “chart review” program in which it paid diagnosis coders to review medical records (also known as “charts”) and identify all medical conditions that the charts supported. Aetna relied on the results of those chart reviews to submit additional diagnosis codes to CMS to obtain additional payments. However, Aetna’s chart reviews did not substantiate some diagnosis codes previously reported by Aetna to CMS. Aetna did not delete or withdraw those diagnosis codes, which would have required Aetna to reimburse CMS. The United States alleges that Aetna used the results of its chart reviews to identify instances where Aetna could seek additional payments from CMS while ignoring those same results when they indicated Aetna was overpaid.

The settlement also resolves further allegations that, for payment years 2018 to 2023, Aetna knowingly submitted or failed to delete or withdraw inaccurate and untruthful diagnosis codes for morbid obesity to increase the payments it received from CMS for beneficiaries enrolled in its MA plans. The medical records for individuals diagnosed as morbidly obese typically include one or more Body Mass Index (BMI) recordings. Aetna submitted or failed to delete inaccurate and untruthful diagnosis codes for morbid obesity for individuals whose recorded BMI was inconsistent with a diagnosis of morbid obesity, and these codes increased the payments made by CMS.

The settlement in this case provides for the whistleblower, a former Aetna risk-adjustment coding auditor, to receive a $2,012,500 share of the settlement amount.

The claims resolved by the settlement are allegations only and there has been no determination of liability.