The U.S. Department of Justice announced that home health provider Monogram Health has agreed to pay $2.4 million to resolve allegations that it submitted unsupported diagnosis codes that inflated payments under the Medicare Advantage program. The settlement covers claims the DOJ described as involving covered coding conduct that increased beneficiaries’ risk scores and, in turn, plan reimbursements from the Centers for Medicare & Medicaid Services (CMS).
The settlement payment includes approximately $1.4 million in restitution and additional amounts and interest to total $2.4 million. The DOJ said the company will pay the recovery plus interest; the source article does not report a further detailed breakdown of interest or other fees beyond the amounts cited.
According to the DOJ and an unsealed whistleblower complaint, Monogram allegedly submitted inaccurate or medically unsupported diagnosis codes to insurers from 2021 through 2023. The complaint identifies specific categories of codes that the government alleges were clinically inaccurate, unsupported by patients’ medical records, or did not require or affect patient care. Those categories include codes for protein-calorie malnutrition, substance use disorder, coagulation and other blood disorders, and angina.
The DOJ contends those codes raised beneficiaries’ risk scores used in the Medicare Advantage risk-adjustment payment system, prompting larger payments from CMS to Medicare Advantage organizations than would otherwise have been paid.
The settlement resolves some claims in a whistleblower suit filed by Dr. Ajay Gupta, a former Monogram nephrologist and regional medical director. The unsealed complaint identifies Cigna and Humana as the Medicare Advantage insurers that contracted with Monogram, although the source notes neither insurer is a party to the settlement.
The DOJ settled the specific claims tied to the covered coding conduct and dismissed other claims and parties in the complaint without prejudice, according to a public affairs official for the U.S. Attorney’s Office for the Central District of California. The source makes clear these are allegations; the settlement does not constitute a determination of liability.
Under Medicare Advantage, CMS pays private insurers a fixed monthly amount per enrollee that is adjusted based on the expected cost of the individual’s care. Diagnosis codes associated with more severe or complex conditions increase a beneficiary’s risk score; higher risk scores yield larger plan reimbursements from CMS.
Providers that participate in risk-based contracts with Medicare Advantage plans can share in the financial benefits tied to higher risk scores. The DOJ said that structure created a financial incentive for Monogram to submit diagnosis codes that produced higher risk scores. The government described the company’s alleged practice as upcoding — submitting codes that portray beneficiaries as having more severe or costly conditions than documented or clinically supported.
Per the DOJ and reporting, Monogram’s settlement totals $2.4 million, which includes roughly $1.4 million in restitution. Under the False Claims Act’s whistleblower provisions, Dr. Ajay Gupta will receive $386,225 from the recovery. The source does not provide additional detail on the allocation of the remaining funds beyond restitution and the whistleblower payment.
The justice department clarified that it only resolved the claims related to the covered coding conduct in the complaint. Other claims and parties named in the complaint were dismissed without prejudice, meaning those claims could potentially be refiled. The DOJ’s statement emphasizes the allegations have not been adjudicated as proven.
Monogram declined to comment, and counsel for the whistleblower did not respond to Healthcare Dive at the time of publication, per the source.
Healthcare Dive placed the Monogram settlement in a broader enforcement context. The article notes another recent provider-side enforcement action: value-based primary care provider Complete Health agreed to pay $14.1 million to settle allegations it submitted unsupported diagnoses to increase Medicare Advantage payments for 2020 through 2023.
The reporting also references intensified federal scrutiny of Medicare Advantage as CMS accelerates audits of health plans’ risk-adjustment submissions. The source cited estimates that federal spending on Medicare Advantage beneficiaries is increasing compared with traditional Medicare, and noted that CMS’s expanded auditing and enforcement activity has accompanied several provider-focused settlements alleging upcoding.
The DOJ provided the settlement information and a public affairs officer described procedural elements of the case. Monogram declined to comment to Healthcare Dive, and the whistleblower’s counsel did not respond to requests for comment by publication time. The source does not report any apology, admission of liability, or operational changes by Monogram as part of the settlement.
The Monogram settlement underscores enforcement priorities around risk-adjustment and coding accuracy in Medicare Advantage. The DOJ action, the whistleblower recovery, and parallel settlements cited by the article signal continued government attention to alleged provider upcoding practices and expanded CMS auditing of Medicare Advantage risk scores.
Clinicians, coding teams, and organizations contracting under risk-based agreements should note the DOJ’s allegations as a reminder of the legal and financial risks tied to submitting diagnosis codes that are not supported by clinical documentation. The source article does not provide guidance or new regulations resulting from the settlement; it reports the DOJ’s announcement and related facts described above.