The United States Attorney in Philadelphia announced that 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 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.
Aetna owns and operates MAOs that offer MA plans to beneficiaries across the country. The United States alleges that Aetna submitted inaccurate and untruthful patient diagnosis data to CMS in order 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. The United States contends that, for payment year 2015, Aetna operated a “chart review” program, under which it retrieved medical records (also known as “charts”) 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, 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 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 $11,500,000 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 settlement provides for the whistleblower, a former Aetna risk-adjustment coding auditor, to receive a $2,012,500 share of the settlement amount.
Jeffrey Newman, JD, MBA, is a whistleblower lawyer whose firm represents healthcare fraud whistleblowers and whistleblowers reporting violations of export controls, tariff evasions, money laundering, and other kinds of WB cases. Mr. Newman and his staff also represent many physician whistleblowers in healthcare fraud cases. Whistleblower laws in the U.S. allow individuals with information about export control violations or tariff fraud to report it under the False Claims Act. The Firm’s website is www.JeffNewmanLaw.com. Attorney Newman can be reached at Jeff@Jeffnewmanlaw.com or at 978-880-4758. for other articles see: http://JeffNewmanLaw.com
