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Washington, D.C. – In a significant move targeting potential healthcare fraud, the U.S. Justice Department has filed a False Claims Act lawsuit against three of the nation’s largest health insurance providers: Aetna Inc. and its affiliates, Elevance Health (formerly Anthem), and Humana. The lawsuit also implicates three prominent insurance brokerage firms – eHealth, GoHealth, and SelectQuote – alleging deceptive practices that resulted in inflated Medicare Advantage payments.

The Justice Department's complaint, unsealed Thursday, details a sophisticated scheme where the insurers allegedly encouraged brokers to inflate patient diagnoses to receive higher payments from Medicare Advantage plans. Medicare Advantage, a popular option for seniors, provides healthcare through private insurance companies that contract with Medicare. Reimbursement rates for these plans are often tied to patient diagnoses, with more complex conditions commanding higher payments.

According to the lawsuit, Aetna, Elevance, and Humana incentivized brokers like eHealth, GoHealth, and SelectQuote to present patients with more severe diagnoses than were accurate. This practice, known as “upcoding,” artificially inflated the risk scores assigned to patients, leading to Medicare paying the insurers more than they were entitled to. The government alleges that these practices occurred over a period of several years, resulting in substantial financial gains for the companies involved.

“The government has a duty to protect the integrity of Medicare Advantage and ensure that taxpayer dollars are spent appropriately,” said a Justice Department spokesperson. “The alleged conduct in this case undermines that integrity and defrauds the American people.”

The False Claims Act allows the government to recover treble damages – three times the amount of the false claims – plus civil penalties. If successful, the lawsuit could result in significant financial penalties for the companies involved.

Key Allegations and Implications:

• Inflated Diagnoses: Brokers allegedly encouraged to exaggerate patient diagnoses to increase risk scores.
• Higher Payments: Resulting in Medicare Advantage plans receiving inflated payments.
• Broad Impact: The lawsuit affects major insurers and brokerage firms, potentially reshaping the Medicare Advantage landscape.
• Financial Risk: Companies face potential treble damages and civil penalties.

This lawsuit is part of a broader effort by the Justice Department to combat healthcare fraud and protect the Medicare program. The investigation highlights the importance of accurate patient diagnosis and the potential for abuse within the Medicare Advantage system. The outcome of this case will likely have a significant impact on how health insurance companies and brokers operate within the Medicare Advantage market and could lead to increased scrutiny of diagnostic coding practices.

All companies named in the lawsuit have denied any wrongdoing. They have pledged to vigorously defend themselves against the allegations.