Complete Health, a value-based primary care provider operating in Florida, Alabama and Colorado, agreed to pay $14.1 million to resolve allegations the company submitted false diagnosis codes to inflate Medicare Advantage (MA) payments. The Department of Justice announced the settlement as the resolution of a qui tam complaint filed under the False Claims Act. The alleged conduct occurred from 2020 through 2023 and was intended to increase the risk-adjusted payments MA plans receive from CMS.
According to the whistleblower suit and DOJ statements, Complete Health’s affiliated providers allegedly mined patient records to identify and submit diagnoses that either did not exist or were not supported by medical evidence. The complaint cites specific conditions used in the alleged upcoding, including opioid use disorder, sedative dependence and major depressive disorder. By adding these diagnoses to patients’ records and to CMS submissions, the suit alleges Complete Health increased the risk scores used to calculate MA payments, thereby inflating reimbursement to insurers that contracted with the company.
Complete Health was founded in 2018 by a private equity firm and manages affiliated providers across three states. The company contracts with Medicare Advantage organizations to provide primary care on a shared-risk basis. Under that arrangement, Complete Health does not bill fee-for-service for each encounter; instead, it receives a portion of an insurer’s MA reimbursement for the patients it treats. The DOJ said that shared-risk contracting created an incentive for the company to maximize MA reimbursement, which the complaint alleges was pursued through improper diagnostic coding practices.
The qui tam suit was filed by Karen Bowers, identified in reporting as a former risk adjustment professional who worked at Viva Health and Blue Cross and Blue Shield of Alabama. Bowers alleges she discovered the problematic coding practices while employed at those insurers. Under the False Claims Act’s whistleblower provisions, Bowers will receive about $2.5 million from the recovery. The DOJ’s announcement indicates the settlement resolves the government’s claims raised in that qui tam action.
The unsealed complaint also accuses Viva Health and Blue Cross and Blue Shield of Alabama of knowingly submitting the disputed diagnosis codes to CMS despite awareness that the codes were incorrect, according to the complaint referenced in the DOJ announcement. The DOJ settlement named Complete Health and did not name those insurers in the department’s settlement announcement; the department did not provide comment in the reporting on the status of allegations against the insurers.
Assistant Attorney General Brett Shumate of the DOJ’s Civil Division emphasized that the settlement reflects the department’s commitment to protecting taxpayer money and ensuring Medicare payments are based on accurate information. The department framed the action within broader enforcement efforts targeting fraud and profiteering in Medicare Advantage as the program expands.
During the same period, CMS has pursued a variety of measures to address overpayments and coding accuracy in MA, including increased audits and changes to how companies record additional diagnoses. The reporting notes CMS finalized a rule this spring that removed one tool insurers used to record additional diagnoses, while other proposed changes were not adopted. Policymakers and regulators across the political spectrum have expressed concern about MA overpayments tied to risk-adjustment coding practices.
The Complete Health settlement is the latest enforcement action highlighting concerns about upcoding in Medicare Advantage. The case underlines how shared-risk contracting arrangements can create incentives to maximize risk scores and MA payments. It also demonstrates the role of qui tam whistleblowers in detecting alleged improper coding and the DOJ’s willingness to pursue civil False Claims Act recoveries.
The broader context cited in reporting includes congressional and regulatory efforts to identify and claw back overpayments to MA plans, accelerated audits by CMS, and debate over policy changes to make MA payments more accurate. This settlement adds to a series of actions — against both large insurers and smaller entities — aimed at curbing improper profit-seeking in the Medicare Advantage program.
The reporting provides the settlement amount, the years alleged (2020–2023), the states where Complete Health operates, the diagnoses cited in the complaint, the whistleblower identity and approximate award, and quotes from the DOJ. The article did not report the specific breakdown of the $14.1 million recovery, details of any admissions of liability by Complete Health, the status of allegations against the insurers named in the complaint beyond the DOJ settlement, or any comment from Complete Health.