The settlement resolves claims that Aetna violated the False Claims Act by submitting unsupported, inaccurate diagnosis codes for Medicare Advantage enrollees to increase risk-adjusted payments.
Aetna will pay $117.7 million to resolve allegations that it inflated Medicare Advantage reimbursements by submitting inaccurate diagnosis codes and failing to correct known errors, the U.S. Department of Justice (DOJ) announced on Wednesday.
Under the Medicare Advantage program, the Centers for Medicare & Medicaid Services (CMS) pays a fixed monthly amount for each enrollee that is adjusted for risk based on documented diagnoses. The sicker the member, the higher the payment.
RELATED: Report: Medicare Advantage overpayments led to billions in premium increases for all seniors
According to the DOJ, Aetna knowingly submitted unsupported diagnosis data to CMS, did not withdraw codes it knew were inaccurate, and falsely certified to CMS that its submissions were truthful. The agency’s complaint focuses on two sets of conduct.
For payment year 2015, Aetna allegedly operated a “chart review” program in which coders reviewed medical records to identify all conditions supported by documentation. While the chart reviews identified unsupported diagnosis codes previously submitted by Aetna, the government claims the company used the reviews only to capture additional codes that generated higher payments and ignored findings showing potential overpayments.
The settlement also resolves allegations that, from payment years 2018 to 2023, Aetna knowingly submitted or failed to delete inaccurate morbid obesity diagnosis codes to increase CMS payments. These accusations were raised by Mary Melette Thomas, a risk‑adjustment coding auditor who filed a qui tam complaint in January 2024. She will receive a $2 million share of the settlement.
The DOJ emphasized that the settlement resolves allegations only. Aetna has not admitted wrongdoing, and no court has determined liability. A company spokesperson told The Wall Street Journal that Aetna disagrees with the DOJ’s industry‑wide allegations and that the settlement should not be interpreted as an admission of liability.