OIG: Aetna received estimated $25.5M in Medicare Advantage overpayments

Aetna received $632,070 in overpayments for Medicare Advantage claims from 2015 to 2016, an audit from HHS' Office of Inspector General found. 

The OIG used the audit sample to estimate the insurer received at least $25.5 million in overpayments during the time period, according to a report published Oct. 2. The government watchdog audited 210 enrollee-years for codes determined high risk for upcoding by the OIG. 

Every major insurer has previously been accused of or settled allegations of upcoding in Medicare Advantage, or making patients appear sicker than they are on paper to receive higher reimbursements from the government. 

OIG recommended that Aetna refund the government $632,070 in the identified overpayments, determine any other overpayments, and continue to improve its compliance procedures. 

CMS did not request the estimated $25.5 million in overpayments because of a CMS ruling that prevents the federal government from collecting extrapolated overpayments before contract year 2018. 

Aetna did not concur with OIG's recommendations or findings in the audit, according to the report. The company also disputed the audit's methodology. 

"We note that, while OIG identified an overpayment amount across our entire contract, that recommendation is not consistent with CMS regulations and is not applicable to the audit at issue. However, we are pleased that OIG recognized the efforts we put into our compliance program," an Aetna spokesperson said in a statement shared with Becker's. 

OIG has audited several other payers for Medicare Advantage overpayments in 2023. 

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