Aetna Settles DOJ Allegations Over Medicare Advantage Diagnosis Codes

Aetna, a health insurance subsidiary of CVS Health, has agreed to a $117.7 million settlement with the U.S. Department of Justice (DOJ) amid allegations of submitting inaccurate diagnosis codes for Medicare Advantage beneficiaries. The investigation highlighted that Aetna provided misleading data to the Centers for Medicare and Medicaid Services (CMS) to inflate risk adjustment payments.

According to DOJ, Aetna did not address discrepancies after submitting these diagnosis codes, falsely certifying the accuracy to CMS. Although the settlement resolves these issues, Aetna admits no liability. Initiated by a whistleblower, formerly a risk-adjustment coding auditor at Aetna, the civil suit concerned the misuse of morbid obesity codes, stemming from a "chart review" program instituted in 2015. This program involved using coders to locate conditions in medical records to justify diagnosis submissions to CMS for additional financial compensation.

The DOJ criticized Aetna's practice of using unsupported diagnosis codes for increased reimbursements and ignoring potential overpayments. Additionally, between 2018 and 2023, Aetna allegedly continued submitting incorrect codes affecting CMS payment calculations, notably concerning morbid obesity. As CMS adjusts Medicare Advantage plan payments based on medical diagnoses and risk calculations, Assistant Attorney General Brett A. Shumate stated the government would continue to enforce regulatory compliance by holding insurers accountable for unsupported submissions that inflate reimbursements.

For additional details, contact insurancenews@cvshealth.com.