Aetna Inc., a national insurer incorporated under the laws of Pennsylvania, 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.
Under the Medicare Advantage 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 for each enrolled Medicare beneficiary. CMS adjusts these monthly payments to account 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 and less for healthier beneficiaries expected to incur lower costs. To make these “risk adjustments,” CMS collects medical diagnosis codes from the MAOs.
“The government pays Medicare Advantage Organizations to facilitate vital healthcare to our seniors and other vulnerable citizens,” said U.S. Attorney Metcalf. “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.”
Aetna owns and operates MAOs that offer MA plans to beneficiaries nationwide. The United States alleges that Aetna submitted inaccurate and untruthful patient diagnosis data to CMS to inflate the 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.
Aetna$117MSettlement by scott.mcclallen
The United States contends that, for payment year 2015, Aetna operated a “chart review” program, under which it retrieved medical records from healthcare providers documenting services provided to Medicare beneficiaries enrolled in Aetna’s MA plans.
Aetna retained diagnosis coders to review those charts to identify all medical conditions that the charts supported and to assign the beneficiaries' diagnosis codes for those conditions. Aetna relied on the results of those chart reviews to submit additional diagnosis codes to CMS that the healthcare providers had not reported for the beneficiaries to obtain additional payments from CMS.
According to the United States, Aetna’s chart reviews did not substantiate some diagnosis codes reported by providers that had previously been submitted by Aetna to CMS. Aetna did not delete or withdraw these inaccurate and untruthful diagnosis codes; however, this 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 improperly failing to use those same results when they provided information about instances where Aetna was overpaid. $106,200,000 of the settlement amount resolves those allegations.
The remaining $11.5 million of the aggregate settlement amount resolves further allegations that, for payment years 2018 to 2023, Aetna obtained increased payments from CMS by knowingly submitting or failing to delete inaccurate and untruthful diagnosis codes for morbid obesity for individuals whose recorded BMI was inconsistent with a diagnosis of morbid obesity.
The settlement related to morbid-obesity codes 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 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 settlement provides for the whistleblower, a former Aetna risk-adjustment coding auditor, to receive a $2,012,500 share of the settlement amount. The qui tam case is captioned United States ex rel. Mary Melette Thomasv. Aetna Inc., et. al., No. 24-cv-339 (E.D. Pa.).
“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). “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, and HHS‑OIG will continue to protect taxpayer funds and the integrity of this vital program.”
The matter was handled in the Eastern District of Pennsylvania by Assistant U.S. Attorneys Peter Carr and Gregory B. in den Berken, former auditor George Niedzwicki, and litigative consultant Lauren M. Cordrey, along with Civil Fraud Section attorney Nelson Wagner and Assistant Director, Edward C. Crooke. HHS-OIG assisted the investigation.
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 https://oig.hhs.gov/fraud/report-fraud/ or 800-HHS-TIPS (800-447-8477).
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