Aetna Agrees to Pay $117.7 Million to Resolve False Claims Act Allegations

Aetna, a national-level insurance company, has agreed to pay $117.7 million to settle allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for members enrolled in its Medicare Advantage plans. The government claimed that between 2011 and 2019, Aetna knowingly caused the submission of unsupported diagnoses to the Centers for Medicare & Medicaid Services, which resulted in inflated risk-adjusted payments intended to reflect the true health status of beneficiaries.

The settlement resolves a qui tam whistleblower lawsuit filed by a former Aetna data analyst who alleged that the company ignored internal audits flagging unsupported chart reviews. Under the False Claims Act, the whistleblower will receive approximately $18.8 million as her share of the recovery. This case is part of a broader government initiative targeting risk adjustment fraud in the Medicare Advantage program. Individuals with knowledge of similar Medicare fraud or improper billing practices are encouraged to consult experienced whistleblower attorneys to understand their potential options.