Although Aetna Inc. (Aetna) entered into a health care fraud settlement with the United States, Aetna refused to agree to compliance-related oversight with HHS-OIG through a CIA. Therefore, as part of the Settlement Agreement, OIG reserved the right to exclude Aetna for the alleged conduct. Because Aetna refused appropriate integrity obligations with OIG, OIG may use various tools to monitor Aetna’s compliance with the Federal health care programs.
PRESS RELEASE
Aetna Agrees to Pay $117.7 Million to Resolve Allegations that it Violated the False Claims Act by Submitting or Failing to Correct Inaccurate Diagnoses for Medicare Advantage Enrollees
Published by the United States Department of Justice | View article on www.justice.gov
Published by the United States Department of Justice | View article on www.justice.gov
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 adjusted 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. To make these “risk adjustments,” CMS collects medical diagnosis codes from the MAOs.