Aetna Inc. has agreed to pay $117.7 million to settle allegations of submitting false diagnosis codes to inflate Medicare payments under the Medicare Advantage (MA) Program. The company allegedly submitted inaccurate diagnosis data to the Centers for Medicare & Medicaid Services (CMS) for its MA plan enrollees, inflating risk adjustment payments it received. Aetna’s chart review program, which aimed to identify additional diagnoses for extra payments, failed to remove inaccurate codes, leading to overpayments. The company also submitted false codes for morbid obesity between 2018 and 2023, increasing payments despite inconsistent medical records. A whistleblower lawsuit prompted the investigation, with the former Aetna employee receiving a $2 million share of the settlement. This resolution highlights the government’s commitment to holding insurers accountable for fraud and protecting taxpayer funds.
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