PHILADELPHIA (KYW Newsradio) — National health insurer Aetna — owned by CVS — has agreed to settle for more than $117 million to end allegations it submitted false patient data to increase its Medicare payout from the government.
According to the U.S. Attorney's Office of the Eastern District of Pennsylvania, Aetna violated the False Claims Act when it submitted false patient diagnoses and failed to remove untruthful ones when it submitted its records to the government for Medicare payments over the course of eight years, between 2015 and 2023.
The diagnoses were submitted as the company sought payments through the government’s Medicare Advantage Program. As part of it, Medicare recipients can opt out of traditional Medicare and get private plans through companies like Aetna.
The Centers for Medicare and Medicaid Services processes the funding requests from companies through the program and pays fixed monthly amounts for every enrolled Medicare recipient. The monthly payments are adjusted based on various risk factors pertaining to how healthy the recipient is.
The U.S. Attorney’s Office has accused Aetna of not only submitting false diagnoses to raise its monthly payouts, but also affirming in writing that the data it was submitting was accurate when it was not.
Prosecutors said Aetna was overpaid by more than $106 million for submitting additional diagnoses that were not accurate. A further $11.5 million was allegedly overpaid between 2018 and 2023 for submitting false diagnoses of morbid obesity for some patients.
In a statement to KYW Newsradio, an Aetna spokesperson said the company continues to disagree with the government’s allegations. They said the settlement should not be seen as an acknowledgement of liability by the company, but a desire to avoid uncertainty around ongoing litigation.