The government alleged Aetna knowingly submitted unsupported diagnosis codes, resulting in overpayments by Medicare.

Aetna Inc. has agreed to pay a total of $117.7 million to resolve two separate sets of allegations under the False Claims Act (FCA) involving its Medicare Advantage (MA) risk-adjustment submissions, according to a Department of Justice press release. The government asserts that Aetna provided CMS with patient diagnosis information that it knew was incorrect, thereby boosting the risk-adjusted payments it received. It further contends that Aetna did not remove the faulty data or return the resulting overpayments, and that the company signed written certifications inaccurately attesting that its submissions were complete and truthful.

Chart review settlement. The larger settlement requires Aetna to pay $106.2 million, including $53.1 million in restitution, to resolve allegations that the company knowingly submitted unsupported diagnosis codes to the Centers for Medicare & Medicaid Services (CMS) for payment year 2015. The United States alleged that Aetna operated a “chart review” program under which it added diagnosis codes not reported by providers but failed to investigate or delete unsupported codes that inflated payments from CMS. The government further asserted that Aetna submitted annual certifications falsely attesting that its data was “accurate, complete, and truthful,” despite knowing that some risk-adjusting codes were unsubstantiated by...

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