CVS Health’s Aetna unit will pay $117.7 million to resolve allegations that it violated the False Claims Act. The U.S. Department of Justice claimed the insurer submitted inaccurate patient diagnosis data for its Medicare Advantage plan members.
Aetna allegedly used faulty data to inflate risk adjustment payments received from the government. The federal program pays higher rates for sicker patients expected to incur greater healthcare costs.
The settlement covers claims that Aetna identified unsupported medical conditions through chart reviews and failed to withdraw inaccurate codes. From 2018 to 2023, the company allegedly submitted false diagnosis codes for morbid obesity for patients whose records did not support the diagnosis.
Aetna did not admit liability as part of the agreement. The company stated it settled the matter to avoid the expense and uncertainty of litigation.