By Jonathan Stempel<\/p>\n
NEW YORK, March 11 (Reuters) – Aetna, a unit of CVS Health, agreed to pay $117.7 million to resolve U.S. government charges it \u200cdefrauded Medicare by knowingly submitting inaccurate diagnosis codes for morbid obesity \u200cand other health conditions in Medicare Advantage Plan enrollees.<\/p>\n
The civil settlement announced by the U.S. Department \u200bof Justice on Wednesday resolves charges that Aetna violated the federal False Claims Act.<\/p>\n
Under Medicare Advantage, also known as Medicare Part C, patients who opt out of traditional Medicare may enroll in private health plans known as Medicare Advantage Organizations, or \u200cMAOs.<\/p>\n
The U.S. Centers for Medicare & \u2060Medicaid Services generally pays MAOs higher amounts for sicker patients, after calculating “risk adjustments” based on diagnosis codes it collects.<\/p>\n
According to the \u2060Justice Department, between 2018 and 2023 Aetna submitted untruthful diagnosis data to CMS for morbid obesity in patients whose reported Body Mass Index was inconsistent with that diagnosis.<\/p>\n
Aetna \u200bwas \u200balso accused of failing to withdraw inaccurate \u200bdiagnosis codes it uncovered during a \u200creview of patients’ medical records for 2015.<\/p>\n
Private insurers receive more than $530 billion annually from the government to care for Medicare Advantage patients, Assistant Attorney General Brett Shumate said in a statement.<\/p>\n
CVS, based in Woonsocket, Rhode Island, said it settled to avoid the uncertainty and expense of litigation.<\/p>\n
“Aetna continues to disagree with the DOJ’s industry-wide \u200callegations, and this settlement should not be \u200bseen as an acknowledgment of liability,” CVS added. \u200bCVS bought Aetna in 2018.<\/p>\n
The \u200bsettlement related to morbid obesity resolves a January 2024 lawsuit \u200cfiled in Philadelphia federal court by Mary \u200bMelette Thomas, an \u200bArizona resident and former Aetna risk adjustment coding auditor.<\/p>\n
She will receive $2.01 million from the settlement, the Justice Department said. The False Claims Act lets \u200bwhistleblowers sue on the government’s \u200cbehalf, and share in recoveries.<\/p>\n
(Reporting by Jonathan Stempel in New York; \u200bAdditional reporting by Susan Heavey and Bhargav Acharya; Editing by Ryan \u200bPatrick Jones, Chizu Nomiyama and Bill Berkrot)<\/p>\n","protected":false},"excerpt":{"rendered":"By Jonathan Stempel NEW YORK, March 11 (Reuters) – Aetna, a unit of CVS Health, agreed to pay…\n","protected":false},"author":3,"featured_media":648733,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":"","_share_on_mastodon":"0"},"categories":[35],"tags":[46411,275670,66324,210,1141,1142,3235,28533,275669,94,67,132,68],"class_list":["post-648732","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-aetna","tag-civil-settlement","tag-cvs-health","tag-health","tag-health-care","tag-healthcare","tag-medicare","tag-medicare-advantage","tag-morbid-obesity","tag-u-s-department-of-justice","tag-united-states","tag-unitedstates","tag-us"],"share_on_mastodon":{"url":"https:\/\/pubeurope.com\/@us\/116212339253056568","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/648732","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/comments?post=648732"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/648732\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media\/648733"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media?parent=648732"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/categories?post=648732"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/tags?post=648732"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}