Federal News
DOJ Resolves Medicare Fraud Claims Against Aetna
March 11, 2026
The Department of Justice (DOJ) has secured a $117.7 million settlement from Aetna Inc. to resolve allegations of submitting inaccurate diagnosis codes to inflate Medicare Advantage payments. This settlement highlights the government's intensified enforcement against healthcare fraud in Medicare programs. Concurrently, General Medicine PC faces ongoing False Claims Act litigation for alleged improper Medicare billing related to nursing home and assisted living services, with a federal court allowing the case to proceed to trial. These developments underscore the DOJ's commitment to holding healthcare providers accountable for accurate Medicare billing and protecting program integrity.
- Why this matters: Procurement professionals and contractors in healthcare and Medicare services should be aware of increased scrutiny and enforcement risks related to billing practices.
- Organizations providing Medicare Advantage or nursing home services must ensure compliance with accurate coding and billing to avoid False Claims Act liabilities.
- The settlements and ongoing litigation signal potential impacts on contract eligibility and reputational risk for healthcare vendors.
- Companies should consider strengthening internal audit and compliance programs to mitigate fraud risks and align with government enforcement priorities.
The US government has pointed out factual disputes entitling it to a jury trial on whether General Medicine submitted false claims to the government for payment, and whether the company did so knowingly.
— Judge Staci M. Yandle
When corporations or individuals threaten the Medicare Advantage program by diverting those limited government resources through fraud, waste, or abuse, we will continue to pursue all available remedies against them.
— David Metcalf, U.S. Attorney for the Eastern District of Pennsylvania
Medicare Advantage relies on accurate reporting and attempts to manipulate the system undermine both the program’s integrity and the beneficiaries it serves. No company is beyond accountability, no matter how large or well known.
— Scott J. Lampert, Acting Deputy Inspector General for Investigations, HHS-OIG
Agencies
United States Department of Justice, US District Court for the Southern District of Illinois, U.S. Department of Health and Human Services, Office of Inspector General, Centers for Medicare & Medicaid Services, US Attorney’s Office for the Eastern District of Pennsylvania
Vendors
Aetna Inc., General Medicine PC
Locations
Sources
- Office of Public Affairs | Aetna Agrees to Pay $117.7 Million to Resolve False Claims Act Allegations | United States Department of Justice · DOJ · Mar 11
- General Medicine Will Continue to Face Nursing Home Fraud Suit · Bloomberg Government News · Mar 11
- Aetna Agrees to $118 Million Settlement in Medicare Fraud Suit · Bloomberg Government News · Mar 11