Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act Suit
Monday, August 24, 2026 - Monogram Health Professional Services PC and Monogram Health Inc., (Monogram Health), headquartered in Tennessee, have agreed to pay $2.4 million to resolve allegations that they violated the False Claims Act by causing the submission of false diagnosis codes in order to increase payments that they received from the Medicare Advantage program.
“When companies submit false diagnosis codes, they unlawfully exploit a system built to support vulnerable seniors,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “This settlement reinforces the Department’s commitment to protecting taxpayer money and ensuring that Medicare Advantage payments are based on accurate information.”
“When it comes to how federal money is being spent, taxpayers deserve to know that this Justice Department is looking out for them,” said First Assistant U.S. Attorney Bill Essayli for the Central District of California. “My office will continue to work to ensure that money for public health programs is spent how it’s intended, as today’s settlement shows.”
“Health care companies that seek to inflate profits by inaccurately reporting the medical conditions of Medicare Advantage enrollees will be held accountable,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the Department of Health and Human Services Office of Inspector General (HHS‑OIG). “This settlement underscores HHS‑OIG’s commitment to protecting the integrity of taxpayer‑funded federal health care programs. Medicare Advantage exists to deliver medically necessary care to beneficiaries, not to serve as a vehicle for improper financial gain.”
Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may opt out of traditional Medicare and enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations, or MAOs. The Centers for Medicare & Medicaid Services (CMS) pays the MAOs a fixed monthly amount for each Medicare beneficiary enrolled in their plans. CMS adjusts these monthly payments to account for various “risk” factors that affect expected health expenditures for the beneficiary. In general, CMS pays MAOs more for sicker beneficiaries expected to incur higher healthcare costs and less for healthier beneficiaries expected to incur lower costs. To calculate the payment amounts, CMS uses a health-based risk adjustment model — the Hierarchical Conditions Category (HCC) model — that takes into account diagnoses reported by healthcare providers.
In general, the more severe the diagnosis or costly the associated treatment, the higher the risk score and the higher the corresponding payments to the MAO. The diagnoses must be supported by the medical record of a face-to-face visit between a patient and a provider, and for outpatient visits, must have required or affected patient care, treatment, or management at the visit.
Monogram provides in-home care and related services to Medicare beneficiaries enrolled in MA Plans pursuant to contracts with certain MAOs. Under these contracts, Monogram was eligible to be paid more by the MAOs if the beneficiaries in its care had higher risk scores because the MAO received higher payments from CMS for those beneficiaries. These risk sharing arrangements gave Monogram a financial incentive to submit additional diagnosis codes in order to increase its patients’ risk scores and the corresponding payments made by CMS.
The settlement announced today resolves allegations that, during the period from Jan, 1, 2021 through Dec. 31, 2023, Monogram knowingly submitted diagnosis codes within the following four HCCs that were not clinically accurate, not supported by documentation in the beneficiary’s medical records, and/or did not require or affect patient care, treatment or management: HCC 21 (Protein-Calorie Malnutrition), HCC 55 (Substance Use Disorder); HCC 48 (Coagulation Defects and Other Specified Hematological Disorders), and HCC 88 (Angina Pectoris). The submission of these diagnosis codes resulted in false claims that inflated the risk scores of the Medicare Advantage beneficiaries, thereby causing CMS to make higher capitated payments to the MAOs than it would have paid without these diagnosis codes.
The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Dr. Ajay Gupta, a physician formerly employed by Monogram. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. Dr. Gupta will receive approximately $380,000 as his share of the recovery in this case. The lawsuit is captioned U.S. ex rel. Dr. Ajay Gupta v. Monogram Health Professional Services, et. al., Case No. 2:22-cv-08758 MWF-JCx (C.D. Cal.).
This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division.
The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Central District of California with assistance from the U.S. Department of Health and Human Services Office of Inspector General.
The investigation and resolution of this matter illustrate the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).
The matter was investigated by Fraud Section Attorney Jennifer Cook and Assistant U.S. Attorney Hunter B. Thomson for the Central District of California.
The claims resolved by the settlement are allegations only and there has been no determination of liability.
U.S. Department of Justice
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Source: Justice.gov
