Aetna's $117.7 Million Settlement for Inaccurate Medicare Codes

Aetna has agreed to a $117.7 million settlement for allegedly submitting inaccurate diagnosis codes for its Medicare Advantage Plan members, as announced by the Department of Justice. The settlement aims to address accusations that Aetna violated the False Claims Act by providing erroneous data, impacting the risk adjustment process essential for fair compensation in managing patients with complex healthcare needs.

The Medicare Advantage system mandates that plans submit diagnosis codes to the Centers for Medicare & Medicaid Services (CMS), adjusting monthly payments based on patients' health status. Aetna was accused of inflating its risk pool by submitting inaccurate codes, and in 2015, utilized patient charts from providers to submit these codes to CMS. The accusation contends Aetna included codes not reported by healthcare providers, resulting in additional CMS payments.

The settlement reserves $106.2 million for allegations related to these chart review practices, while $11.5 million addresses claims from 2018 to 2023 where Aetna reportedly submitted unsupported diagnosis codes, like morbid obesity, leading to CMS overpayments. Scott J. Lampert of the U.S. Department of Health and Human Services, Office of Inspector General, stressed accurate reporting's role in upholding the Medicare Advantage program's integrity. Assistant Attorney General Brett A. Shumate confirmed the Department of Justice's commitment to overseeing these practices, noting that private insurers receive over $530 billion annually for patient care, necessitating vigilance against improper reimbursement inflation.