$673 Million in Settlements and Counting
In the span of 18 months, the DOJ collected $556 million from Kaiser and $117.7 million from Aetna over risk adjustment practices. Both cases centered on the same structural problem: retrospective programs designed to add diagnosis codes without adequate clinical support, and without any mechanism to remove codes that shouldn’t have been submitted.
The Aetna settlement, announced March 11, 2026, is particularly instructive. $106.2 million covered an add-only chart review program from payment year 2015. Another $11.5 million addressed false morbid obesity codes submitted from 2018 through 2023. The whistleblower was a former Aetna risk adjustment coding auditor who saw the program’s design from the inside and concluded it was structured to inflate payments.
These settlements aren’t outliers. They’re the new enforcement baseline. OIG’s February 2026 Medicare Advantage Industry-wide Compliance Program Guidance explicitly named add-only chart reviews as a high-risk practice. Any plan still running a one-way retrospective program is operating under a regulatory spotlight.
The Structural Flaw in Add-Only Programs
Add-only retrospective programs create a predictable problem: over time, a plan’s submitted diagnosis codes drift upward while the clinical reality of its members doesn’t change at the same rate. Members accumulate HCCs from prior-year reviews that may no longer reflect active conditions. Codes go in. Codes never come out. The asymmetry compounds year after year.
CMS monitors this at the population level. When a plan’s risk scores rise faster than its clinical outcomes improve, that’s exactly the pattern V28 was designed to correct and RADV audits are designed to catch. The Aetna case demonstrated that even a single program year of add-only activity can generate nine-figure liability when the government decides to investigate.
The cultural problem is just as deep as the technical one. Coding teams have been measured on codes added for years. Productivity dashboards track adds. Bonuses reward volume. Removing an unsupported code looks like a loss on the scorecard. Until leadership redefines what counts as a win, the incentive structure will keep producing the same regulatory exposure.
What a Defensible Program Looks Like
Two-way retrospective review treats every chart review as both an opportunity and an audit. Coders identify missed diagnoses (adds) and flag unsupported ones (deletes). Every HCC gets validated against MEAT-based clinical evidence. Codes that lack adequate documentation support get removed before they become liabilities on the plan’s balance sheet.
Explainable AI makes this scalable. Tools that scan charts and link each coding recommendation to specific evidence in the clinical note give coders the context they need to make accurate decisions in both directions. The system shows which MEAT elements are present, which are missing, and where documentation is ambiguous. The coder validates. The AI supports. The audit trail builds itself.
This approach also changes how plans interact with providers. Instead of sending provider queries only when codes need to be added, two-way programs send queries when documentation needs strengthening or when previously submitted codes lack current support. That feedback loop improves documentation quality over time, which reduces future audit exposure across the entire book.
The Transition That Can’t Wait
Every month a plan continues running an add-only retrospective program is another month of unmitigated regulatory exposure. The DOJ settlements established the precedent. The OIG guidance formalized the risk. The question isn’t whether one-way programs will face consequences. It’s when.
Plans restructuring around Retrospective HCC Coding workflows that validate, clean, and defend submitted diagnoses through two-way review are doing what CMS has been signaling for years. They’re treating supplemental data submission as a two-way street: adding what’s missing and removing what can’t be supported. That’s the defensible model. The add-only era is over, and the financial proof is in the settlement amounts.
Oscar James S