On March 11, the U.S. Department of Justice and U.S. Attorney’s Office announced that Aetna, a national health insurer, has agreed to pay $117,700,000 to settle alleged violations of the False Claims Act (FCA). The government was investigating Aetna for submitting inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan beneficiaries, which increased Aetna’s reimbursement payments from Medicare.
Medicare Advantage Plans are offered by commercial insurers as an alternative for Medicare beneficiaries who opt out of traditional Medicare. The Centers for Medicare & Medicaid Services (CMS) reimburses the commercial insurers a fixed monthly amount that is based on certain risk and health factors of its Medicare Advantage Plan beneficiaries, which are largely determined by the diagnosis codes the Medicare Advantage insurer provides to CMS.
In the Aetna investigation, the government reviewed claims that dated back to 2015, and determined that Aetna had submitted diagnosis codes that were not substantiated by the patients’ medical records. Similarly, for payment years 2018 through 2023, the investigation identified inaccurate diagnosis codes that Aetna submitted for morbid obesity where, in fact, the patients’ BMI (body mass index) was not consistent with such diagnosis.
Acting Deputy Inspector General for Investigations, Scott J. Lampert, of the U.S. Department of Health and Human Services, Office of Inspector General commented that this Aetna settlement “makes clear that no company is beyond accountability, no matter how large or well known.”
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