What's Happening?
Aetna has agreed to pay $117.7 million to settle allegations from the Department of Justice (DOJ) that it submitted false or inaccurate diagnoses to increase Medicare Advantage payments. The settlement addresses claims that Aetna operated a chart review
program in 2015, where diagnosis coders were paid to identify medical conditions in patient records, some of which were unsupported but still submitted to the Centers for Medicare & Medicaid Services (CMS) for higher reimbursements. Additionally, between 2018 and 2023, Aetna allegedly submitted inaccurate diagnoses of morbid obesity to boost payments. These allegations were initially brought forward by a whistleblower in Pennsylvania. Aetna maintains that the settlement is not an admission of liability but a means to avoid prolonged litigation.
Why It's Important?
This settlement underscores the ongoing scrutiny and regulatory challenges faced by private insurers participating in Medicare Advantage, a program that costs the government over $530 billion annually. The case highlights the potential for abuse in the system, where inaccurate coding can lead to inflated reimbursements, impacting federal spending and potentially leading to higher costs for taxpayers. The DOJ's action serves as a warning to other insurers about the consequences of submitting unsupported diagnoses. For Aetna, the settlement allows the company to focus on its Medicare Advantage plans without the distraction of litigation, although it may face reputational damage and increased regulatory oversight.
