Aetna Inc., Medicare Advantage Scheme, Pennsylvania 2023

Aetna Inc., a national insurer incorporated under the laws of Pennsylvania, has agreed to pay $117,700,000 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 in order to increase its payments from Medicare.

The United States alleges that Aetna submitted inaccurate and untruthful patient diagnosis data to CMS in order 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 settlement announced today resolves these allegations, which stem from Aetna’s use of a ‘chart review’ program in which it paid diagnosis coders to review medical records 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 also alleges 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 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,’ he added.

Aetna Inc., Defendant, Philadelphia, Pennsylvania. The settlement resolves allegations that Aetna submitted false claims to Medicare Advantage Program. Outcome: Settlement of $117,700,000. Date: [No specific date mentioned] but the year is 2023.

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