A whistleblower, a former Aetna risk-adjustment coding auditor, will receive $2 million.
Aetna, the health insurer subsidiary of CVS Health, 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 enrollees.
The Department of Justice alleges that Aetna submitted inaccurate and untruthful diagnosis data to the Centers for Medicare and Medicaid Services to inflate its risk adjustment payments to gain payment from Medicare. Aetna failed to withdraw the inaccurate and untruthful diagnosis data and repay CMS, the DOJ said. Further, Aetna was accused of falsely certifying in writing to CMS that the data was accurate and truthful.
The settlement announced on March 11 resolves these allegations, but there has been no determination of liability, the DOJ said.
A civil case on morbid obesity codes was brought in federal court in Pennsylvania by a whistleblower, a former Aetna risk-adjustment coding auditor, who will receive a $2 million share of the settlement amount.
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 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, the DOJ said.
However, Aetna’s chart reviews did not substantiate some diagnosis codes. Aetna did not delete or withdraw these codes, which would have required Aetna to reimburse CMS, the DOJ said. Aetna was accused of using the results of its chart reviews to identify instances where it could seek additional payments 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 submitted or failed to delete or withdraw inaccurate and untruthful diagnosis codes for morbid obesity.
The medical records for individuals diagnosed as morbidly obese typically include one or more Body Mass Index (BMI) recordings. Some diagnosis codes were inconsistent with a diagnosis of morbid obesity, and these codes increased the payments made by CMS, the DOJ said.
The whistleblower civil case was filed in federal court in the Eastern District of Pennsylvania.
CMS pays Medicare Advantage plans a fixed monthly amount adjusted for health factors in risk adjustments based on medical diagnosis codes.
“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.”
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