Aetna Inc., a national insurer incorporated under the laws of Pennsylvania, has agreed to pay $117,700,000 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 in order to increase its payments from Medicare.
Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may opt out of traditional Medicare and enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations, or MAOs. The Centers for Medicare & Medicaid Services (CMS) pays MAOs a fixed monthly amount adjusted for various risk factors that affect expected health expenditures for the beneficiary. In general, CMS pays MAOs more for sicker beneficiaries expected to incur higher healthcare costs. To make these “risk adjustments,” CMS collects medical diagnosis codes from the MAOs.
The United States alleges that Aetna submitted inaccurate and untruthful patient diagnosis data to CMS in order 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 was accurate and truthful. The settlement announced today resolves these allegations.
“The government pays private insurers over $530 billion each year to care for Americans enrolled in Medicare Advantage,” said Assistant Attorney General Brett A. Shumate of 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 government pays Medicare Advantage Organizations to facilitate vital healthcare to our seniors and other vulnerable citizens. When corporations or individuals threaten the Medicare Advantage program by diverting those limited government resources through fraud, waste, or abuse, we will continue to pursue all available remedies against them,” said U.S. Attorney David Metcalf for the Eastern District of Pennsylvania.
“Medicare Advantage relies on accurate reporting and attempts to manipulate the system undermine both the program’s integrity and the beneficiaries it serves,” said Acting Deputy Inspector General for Investigations Scott J. Lampert of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). “This 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, and HHS‑OIG will continue to protect taxpayer funds and the integrity of this vital program.”
The United States contends that, for payment year 2015, Aetna operated a “chart review” program in which it paid diagnosis coders to review medical records (also known as “charts”) and identify all medical conditions that the charts supported. Aetna relied on the results of those chart reviews to submit additional diagnosis codes to CMS to obtain additional payments. However, Aetna’s chart reviews did not substantiate some diagnosis codes previously reported by Aetna to CMS. Aetna did not delete or withdraw those diagnosis codes, which would have required Aetna to reimburse CMS. The United States alleges that Aetna used the results of its chart reviews to identify instances where Aetna could seek additional payments from CMS while ignoring those same results when they indicated Aetna was overpaid.
The settlement also resolves 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 MA plans. The medical records for individuals diagnosed as morbidly obese typically include one or more Body Mass Index (BMI) recordings. Aetna submitted or failed to delete inaccurate and untruthful diagnosis codes for morbid obesity for individuals whose recorded BMI was inconsistent with a diagnosis of morbid obesity, and these codes increased the payments made by CMS.
The civil settlement related to morbid obesity resolves a lawsuit filed under the whistleblower provisions of the False Claims Act, which permit private parties to sue on behalf of the government when they believe that a defendant has submitted false claims for government funds and receive a share of any recovery. The qui tam case is captioned United States ex rel. Mary Melette Thomas v. Aetna Inc., et. al., number 24-cv-339 in U.S. District Court for the Eastern District of Pennsylvania. The settlement in this case provides for the whistleblower, a former Aetna risk-adjustment coding auditor, to receive a $2,012,500 share of the settlement amount.
The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Eastern District of Pennsylvania, in conjunction with HHS-OIG.
The investigation and resolution of this matter illustrate the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at www.oig.hhs.gov/fraud/report-fraud or 800-HHS-TIPS (800-447-8477).
The matter was handled by Fraud Section Attorneys Nelson Wagner and Edward Crooke and Assistant U.S. Attorneys Peter Carr and Gregory B. in den Berken, and Civil Chief Gregory David, for the Eastern District of Pennsylvania.
The claims resolved by the settlement are allegations only and there has been no determination of liability.
