Aetna has agreed to pay $117.7 million to resolve allegations that it violated the False Claims Act by submitting or failing to withdraw inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan enrollees to increase its payments from Medicare. The U.S. Department of Justice announced the settlement this week.

"The government pays private insurers over $530 billion each year to care for Americans enrolled in Medicare Advantage," said Brett A. Shumate, assistant attorney general in the Justice Department's Civil Division. "We will continue to hold accountable insurers that knowingly submit inaccurate or unsupported diagnoses to improperly inflate reimbursement."

The department contends that for payment year 2015, Aetna operated a "chart review" program in which it paid diagnosis coders to review medical records and identify all medical conditions that the charts supported. Aetna relied on the results to submit additional diagnosis codes to CMS to obtain further payments. However, Aetna's chart reviews did not substantiate some diagnosis codes previously reported by Aetna to CMS.

Medicare Advantage beneficiaries may opt out of traditional Medicare and enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations. The Centers for Medicare & Medicaid Services pays these organizations a fixed monthly amount. This amount is adjusted for various risk factors that affect expected health expenditures for the beneficiary. In general, CMS pay more for sicker beneficiaries expected to incur higher health care costs. CMS collects medical diagnosis codes to make these risk adjustments.

The Justice Departmnet alleges that Aetna:

  • Submitted inaccurate and untruthful patient diagnosis data to CMS to inflate the risk adjustment payments it received from CMS;
  • Failed to withdraw the inaccurate and untruthful diagnosis data and repay CMS; and
  • Falsely certified in writing to CMS that the data were accurate and truthful.

The settlement resolves these claims, as well as further allegations that for payment years 2018 to 2023, Aetna knowingly submitted or failed to delete or withdraw inaccurate and untruthful diagnosis codes for morbid obesity to increase the payments it received from CMS for beneficiaries enrolled in its Medicare Advantage plans.

"Medicare Advantage relies on accurate reporting, and attempts to manipulate the system undermine both the program's integrity and the beneficiaries it serves," said Scott J. Lampert of the U.S. Department of Health and Human Services Office of Inspector General. "Today's settlement makes clear that no company is beyond accountability, no matter how large or well known. Those who seek to exploit Medicare Advantage should expect to be identified and held responsible."

NOT FOR REPRINT

© Touchpoint Markets, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to TMSalesOperations@arc-network.com. For more information visit Asset & Logo Licensing.