Aetna Inc., a subsidiary of CVS Health, has agreed to pay $117.7 million to settle allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage enrollees, thereby inflating payments from the Centers for Medicare & Medicaid Services (CMS). The settlement was announced by the U.S. Attorney’s Office for the Eastern District of Pennsylvania on March 11, 2026.
The government’s allegations centered on Aetna’s “chart review” program for the 2015 payment year. Through this program, Aetna retrospectively reviewed medical records to identify additional diagnoses that could justify higher payments from CMS. However, the company allegedly failed to delete or withdraw unsupported diagnosis codes identified during these reviews, which would have necessitated repayment to CMS. This portion of the settlement accounts for $106.2 million.
Additionally, between 2018 and 2023, Aetna was accused of submitting or failing to delete inaccurate diagnosis codes for morbid obesity. This issue arose when the recorded body mass index of members did not support such diagnoses. A whistleblower lawsuit filed by a former Aetna risk-adjustment coding auditor brought these allegations to light. The whistleblower will receive over $2 million from the settlement. This aspect of the settlement amounts to $11.5 million.
In response to the settlement, Aetna stated, “Aetna continues to disagree with the DOJ’s industry-wide allegations, and this settlement should not be seen as an acknowledgment of liability. Instead, we are now able to avoid the uncertainty and further expense of prolonged litigation.” The company emphasized its commitment to delivering quality care to its Medicare Advantage members.
This settlement is part of a broader trend of increased scrutiny over risk-adjustment practices in the Medicare Advantage industry. In January, Kaiser Permanente agreed to a record $556 million settlement, and in 2023, Cigna reached a $172 million agreement with the government over similar allegations.
Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division commented, “We will continue to hold accountable insurers that knowingly submit inaccurate or unsupported diagnoses to improperly inflate reimbursement.” This statement underscores the government’s commitment to ensuring the integrity of the Medicare Advantage program.
The False Claims Act remains a central enforcement tool in addressing alleged fraud, waste, and abuse involving government healthcare programs. The claims resolved by this settlement are allegations only, and there has been no determination of liability.
For more detailed information, refer to the original article on Law.com.