Aetna Fraud Report 2012
Below is the Aetna Fraud Report for 2012. The report is an updated history of Aetna’s felonious misconduct.
Aetna Fraud Report
Aetna 2012 Financials
19% denial rate (Healthcare.Gov, Kaiser, AMA)
CEO compensation: $9.7 Million (according to AP and Wall Street Journal)
$499.2 million profit (CNBC)
$8.92 billion premium revenue (CNBC)
82% medical loss ratio (CMS)
21% increase in premium prices for small employers as of April 2012 (LA Times reports)
Aetna Board of Directors (Responsible for Denials)
Fernando Aguirre – CEO of Chiquita Brands
Mark Bertolini – CEO of Aetna
Frank Clark – CEO of Commonwealth Edison
Betsy Cohen – CEO of Bancorp
Molly Coye, MD – CIO of UCLA Health System
Roger Farah – COO of Ralph Lauren
Barbara Franklin – former US Secretary of Commerce
Jeffrey Garden – Yale University
Gerald Greenwald – CEO of United Airlines
Ellen Hancock – CEO of Exodus
Richard Harrington – CEO of Thompson Corp
Edward Ludwig – Chairman of Dickinson and Company
Joseph Newhouse – Professor of Health Management Harvard University
History of Non-Medicare Fraud
Fined $1,000,000 - December 2012
Fined $120,000,000 - December 2012
Fined $15,000,000 - September 2012
Fined $850,000 – October 2010
Fined $750,000 – February 2010
Fined $256,500 – November 2009
Fined $20 million – February 2009
Fined $5.1 million – February 2009
Fined $6.27 million – August 2003
Fined $50,000 – June 2002
Fined $1.4 million – September 2001
Fined $1.15 million – November 2001
Fined $1.9 million – December 2000
Fined $4.5 million – December 1995
Fined $89 million - December 1994
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Medicare Fraud Fines:
Non-Medicare Fines: $268,396, 500
Total Fraud Fines: $268,396,500
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According to the American Medical Association, Aetna has been fined $8,325,232 by state governments since 2000 for failing to pay physicians in a timely manner.
According to the Ohio Department of Insurance, Aetna was fined $2,000,000 from pocketing employee state income taxes and giving it to Aetna company executives instead in 2009.
Aetna fined $120,000,000 in December 0f 2012 for purposefully underpaying out of network claims.
CPT Codes Most Downcoded by Insurance Companies:
Code: Medicare Rate: Usual Downcoding Amount
99204 (level 4 new office visit) $170.47 $43.13
99203 (leve 3 new office visit) $110.92 $59.55
99202 (level 2 new office visit) $76.88 $34.04
99201 (level 1 new office visit) $44.77 $32.11
99214 (level 4 established patient) $111.39 $38.21
99213 (level 3 established patient) $74.46 $36.93
99212 (level 2 established patient) $44.77 $29.69
99215 (level 5 established patient) $149.60 $108.47
99233 (level 3 hospital progress note) $108.67 $34.01
99232 (level 2 hospital progress note) $75.78 $32.89
99231 (level 1 hospital follow up) $42.12 $33.66
(Source: AMA)
In 2003, Aetna settled with and paid members of the American Dental Association $6,270,000 for downcoding their claims on purpose in order to get profit for their shareholders and executives.
In 2002, The American Urological Association sent a letter to Aetna saying ” Aetna’s business practices are viewed by many physicians and non-physician health care professionals as barriers to care and obstacles to the development of and maintenance of the patient-physician relationship.” In the letter, the AUA states that Aetna routinely downcodes their claims on purpose in order to reimburse the physicians so that they can therefore give as much profit to their executives and shareholders as possible. The AUA lists the following CPT codes as being the most downcoded: 10120, 10121, 53670, 53675, 16020, 16025, 78480, 78460-78465, 78478. CPT modifiers are: 21, 22, 25, 50,51, 52, 59, 80.
Aetna Fraud Report 2012
Listed above is an updated history of Aetna’s felonious misconduct. Aetna has already racked up over $1,000,000 in fines for fraud so far in 2013. Stay tuned to see just how many fines Aetna will receive this year.
