Aetna pays $117.7M to settle FCA case over one-way chart reviews and unsupported obesity codes

A chart review that adds diagnoses but never deletes the unsupported ones. A morbid obesity code on a chart where the recorded BMI doesn't back it up. Those are the two coding patterns at the center of Aetna's $117.7 million False Claims Act settlement, and both are things a working coder touches.

On March 10, 2026, the U.S. Attorney's Office for the Eastern District of Pennsylvania announced, alongside the Justice Department's Civil Division, that Aetna Inc. agreed to pay $117,700,000 to resolve allegations that it submitted, or failed to withdraw, inaccurate and untruthful diagnosis codes for its Medicare Advantage enrollees to inflate the risk-adjustment payments it received from CMS. The settlement resolves civil allegations only. There's no determination of liability.

How the money splits between two coding patterns

The settlement isn't one allegation. It's two, with a separate dollar figure on each, and that split is the useful part for a coder.

The $106.2 million piece is the older, larger problem. The $11.5 million piece is the one that came from a whistleblower, and it's the one with the cleanest coding lesson.

Pattern one: a chart review that only ran one way

For payment year 2015, the government alleges Aetna ran a chart-review program: it pulled medical records from providers, had coders review them for every condition the charts supported, and submitted additional diagnosis codes that the providers hadn't reported, which raised Aetna's payments from CMS.

That part, on its own, is ordinary retrospective review. The alleged problem was the other direction. Those same chart reviews showed that some diagnosis codes Aetna had already submitted were not supported by the records. Deleting them would have meant repaying CMS. According to the government, Aetna didn't delete or withdraw them. It used the reviews to find money it was owed and ignored the same reviews when they showed money it owed back.

That's the line. A chart review or retrospective review that only ever adds risk is the pattern the government keeps naming. The same review has to run both ways, and the unsupported codes it surfaces have to come out.

Pattern two: morbid obesity codes the BMI didn't support

For payment years 2018 through 2023, the government alleges Aetna submitted, or failed to delete, diagnosis codes for morbid obesity for enrollees whose recorded BMI was inconsistent with that diagnosis, and that those codes increased its CMS payments. Morbid obesity is a risk-adjusting diagnosis, so coding it where the record doesn't support it inflates the risk score the payment is built on.

This is a clinical-validation point, and it's a clean one. A BMI reading in the chart is not, by itself, the diagnosis. Morbid obesity has to be documented by the provider as a diagnosis, and the clinical picture, including the recorded BMI, has to match. When the number on the chart doesn't line up with the diagnosis being coded, that's exactly the kind of mismatch an audit looks for. Run the documentation against the MEAT criteria before the code goes out, not after a payer pulls the chart.

Who brought the case, and what the settlement does not say

The morbid obesity allegations resolve a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act. The whistleblower, a former Aetna risk-adjustment coding auditor, will receive $2,012,500 of the settlement. The case is captioned United States ex rel. Mary Melette Thomas v. Aetna Inc., et al., No. 24-cv-339 (E.D. Pa.).

It's worth being precise about what a civil settlement is. Aetna resolved these allegations without any admission of liability, and there's been no court determination that the conduct occurred. The relevant takeaway for a coder isn't whether Aetna did it. It's that the government has now put a price on two specific coding patterns, and named the documentation gap behind each.

Where this lands for risk-adjustment coders

This is the same enforcement theme behind the Kaiser $556 million settlement and the Matrix and HealthFair settlement we covered earlier: the government targeting risk-adjustment programs that add diagnoses without supporting documentation. Aetna's case sharpens two points a coder can act on directly.

You don't control the chart-review or addendum program your organization runs. You do control whether a single diagnosis in front of you is supported before you submit it, and whether a code you can't support comes out instead of staying in. As the quote from the Justice Department's Civil Division put it, the government "will continue to hold accountable insurers that knowingly submit inaccurate or unsupported diagnoses to improperly inflate reimbursement." The defense is the same thing good coding already is: submit a diagnosis the record supports, and delete the ones it doesn't.