The DOJ reports that a healthcare whistleblower will receive an award under the False Claims Act (FCA) for the complaint they filed against Aetna Inc. Aetna agreed to pay $117,700,000 to resolve allegations that it submitted false diagnosis codes to increase Medicare reimbursement payments. The allegations were brought forward by a former Aetna risk-adjustment coding auditor whistleblower, who will receive a $2,012,500 share of the settlement amount.
The Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage Organizations (MAOs) like Aetna to offer private health plans, generally paying MAOs more for sicker beneficiaries because they are expected to incur higher healthcare costs. MAOs submit medical diagnosis codes to CMS to make “risk adjustments” for these payments.
The United States alleged that, “Aetna submitted inaccurate patient diagnosis codes to CMS in order to inflate the risk adjustment payments it received from CMS, failed to withdraw the inaccurate and untruthful diagnosis data and repay CMS, and falsely certified in writing to CMS that the data was accurate and truthful.” Such healthcare schemes undermine the government’s ability to provide affordable medical care to the most disadvantaged population.
“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. Those who seek to exploit Medicare Advantage should expect to be identified and held responsible, and HHS‑OIG will continue to protect taxpayer funds and the integrity of this vital program.”
The whistleblower brought the allegations forward under the whistleblower, or qui tam, provisions of the False Claims Act. These provisions allow private citizens to submit allegations to the government and be awarded 10-30% of the penalties collected. The announcement emphasized the importance of whistleblowers in combating healthcare fraud and encouraged them to report complaints of fraud, waste, abuse, and mismanagement to the Department of Health and Human Services.
The claims resolved by the settlement agreement are allegations only. There has been no determination of liability.