Last summer, I wrote about the DOJ and HHS relaunching their joint False Claims Act Working Group, with Medicare Advantage risk adjustment fraud listed as one of its top enforcement priorities. The Aetna settlement announced earlier this month is a direct example of that initiative delivering results.

What Happened

Aetna has agreed to pay $117.7 million to resolve allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage enrollees in order to inflate the risk-adjusted payments it received from CMS.

Under the Medicare Advantage program, CMS pays insurers a fixed monthly amount per enrollee that is adjusted based on how sick that enrollee is. The sicker the patient, the higher the payment. The government alleges that Aetna exploited this system in two ways:

1. For payment year 2015, Aetna ran an internal “chart review” program in which it hired diagnoses coders to review patient medical records. When those reviews identified diagnoses that could generate additional payments, Aetna submitted them to CMS. But when the same reviews showed that previously submitted codes were unsupported and Aetna was overpaid, Aetna did not delete those codes or return the money.
2. For payment years 2018 through 2023, Aetna submitted or failed to withdraw inaccurate diagnosis codes for morbid obesity for patients whose recorded BMI did not meet the clinical threshold for that diagnosis.

The morbid obesity portion of the case was brought...

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