Aetna has agreed to pay $117.7 million to settle allegations that it submitted false or inaccurate diagnoses to juice Medicare Advantage payments.
Per an announcement from the Department of Justice, the settlement resolves allegations that in 2015 the insurer operated an MA chart review program in which diagnosis coders were paid to review medical records and identify medical conditions supported by those documents.
DOJ said, however, that some diagnostic codes identified in these reviews were not fully supported, yet were still submitted to the Centers for Medicare & Medicaid Services to secure higher payouts.
The settlement also resolves allegations that, between 2018 and 2023, Aetna knowingly submitted, or failed to withdraw, inaccurate diagnoses of morbid obesity to boost payments from CMS. These claims were first brought forward by a whistleblower in Pennsylvania, the DOJ said.
These claims also increased the payments received from CMS, per the DOJ.
“The government pays private insurers over $530 billion each year to care for Americans enrolled in Medicare Advantage,” said Assistant Attorney General Brett Shumate of the Justice Department's Civil Division in the press release. “We will continue to hold accountable insurers that knowingly submit inaccurate or unsupported diagnoses to improperly inflate reimbursement.”
An Aetna spokesperson told Fierce Healthcare that the insurer "continues to disagree with the DOJ’s industry-wide allegations, and this settlement should not be seen as an acknowledgment of liability."
"Instead, we are now able to avoid the uncertainty and further expense of prolonged litigation, as we maintain our focus on delivering first-in-class member experience across our Medicare Advantage plans," they said.
Phillips & Cohen, the law firm representing the whistleblower plaintiff, celebrated the settlement in a statement. The whistleblower alleged to have witnessed the obesity upcoding while working for Aetna.
“It’s unfair to patients to be coded as morbidly obese when they’re not,” said Jeffrey Dickstein, a Phillips & Cohen partner who represented the plaintiff, “and it’s unfair to the government to pay for medical care for conditions that don’t exist.”