Aetna Owes $117 Million After Medicare Coding Mistakes

The insurance arm of CVS Health, Aetna, has agreed to pay $117. 7 million to settle federal claims that it misrepresented patient diagnoses on Medicare Advantage plans. The lawsuit alleged that from 2018 to 2023, Aetna filed false diagnosis codes for morbid obesity and other conditions. These codes helped the company receive higher payments from Medicare because the Centers for Medicare & Medicaid Services use them to adjust risk and determine how much a plan should get. In some cases, the reported body‑mass index did not match the diagnosis of morbid obesity. Aetna also failed to correct inaccurate codes that were discovered during a review of records from 2015.The U. S. Department of Justice said the settlement ends accusations that Aetna violated the False Claims Act. It also resolves a lawsuit brought by former risk‑adjustment auditor Mary Melette Thomas, who will receive about $2 million from the payout. The payment is part of a broader effort to protect Medicare’s $530 billion annual budget for private plans. Aetna maintains that it disagrees with the allegations and that the settlement is not an admission of wrongdoing. The company acquired Aetna in 2018 and has since faced scrutiny over its billing practices.