Aetna has agreed to pay $117.7 million to resolve allegations that it violated the False Claims Act by submitting inaccurate or untruthful diagnosis codes for its Medicare Advantage Plan enrollees, according to a Department of Justice press release.
The alleged practice can result in fraudulent overpayments to Medicare Advantage plans, which United States Attorney General David Metcalf said is a diversion of government resources.
"The government pays Medicare Advantage Organizations to facilitate vital healthcare to our seniors and other vulnerable citizens," Metcalf said in the press release.
"When corporations or individuals threaten the Medicare Advantage program by diverting those limited government resources through fraud, waste or abuse, we will continue to pursue all available remedies against them."
Medicare Advantage operates by having plans submit diagnosis codes to the Centers for Medicare & Medicaid Services (CMS) to determine the monthly payment each plan will receive. Those diagnosis codes inform risk adjustment, which ensures plans that cover sicker or more complex patients -- meaning patients who are more expensive to cover -- will get higher monthly payments.
The lawsuit contends that Aetna submitted diagnosis codes to CMS that inaccurately or untruthfully inflated its risk pool.
In 2015, the payer received charts from its contracted provider partners for individuals covered by Aetna's Medicare Advantage plan. Typically, Medicare Advantage plans use...
The primary court in the city of Chefchaouen sentenced an individual to six months in prison after he was prosecuted for spreading false information. The case stems from his claims about the where...