Aetna to Pay $117 Million to Settle Medicare Advantage Fraud Allegations
Health insurance giant Aetna agreed to pay $117.7 million to the federal government to resolve charges that it improperly received millions in Medicare Advantage payments by falsifying patient diagnosis data to claim patients were sicker than they actually were.
According to the Department of Justice (DOJ), the health insurer submitted false patient diagnosis data for enrollees in its Medicare Advantage Plan to the Centers for Medicare & Medicaid Services (CMS), with the data claiming that patients were morbidly obese.
Under Medicare Advantage, CMS pays a fixed monthly amount for each enrollee, adjusted for risk based on documented diagnoses.
The data was allegedly inaccurate and untruthful to inflate the payments Aetna received from CMS. The health insurer also failed to withdraw the inaccurate data and falsely certified in writing that the data was accurate and truthful.
The incidents occurred in 2015 as well as from 2018 to 2023.
“Medicare Advantage relies on accurate reporting and attempts to manipulate the system undermine both the program’s integrity and the beneficiaries it serves,” said Acting Deputy Inspector General for Investigations Scott J. Lampert of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). “Today’s settlement makes clear that no company is beyond accountability, no matter how large or well known.”
As part of the settlement, whistleblower Mary Melette Thomas, who served as a risk-adjustment coding auditor and filed the complaint in 2024, will receive $2 million.
In a statement Aetna pushed back against the allegations.
“Aetna continues to disagree with the DOJ’s industry-wide allegations, and this settlement should not be seen as an acknowledgment of liability,” a CVS spokesperson said over email. “Instead, we are now able to avoid the uncertainty and further expense of prolonged litigation, as we maintain our focus on delivering first-in-class member experience across our Medicare Advantage plans.”
Aetna was acquired by CVS Health in November 2018.
