DOJ Settled With the In-Home Vendor, Not the Health Plan, Over Four Medicare Advantage Codes
- Monogram Health Professional Services PC and Monogram Health Inc., headquartered in Tennessee, agreed on 24 August 2026 to pay $2.4 million to resolve False Claims Act allegations that they caused the submission of false diagnosis codes to increase Medicare Advantage payments, covering conduct from 1 January 2021 to 31 December 2023.
- The Justice Department named four specific Hierarchical Condition Categories: HCC 21 for protein-calorie malnutrition, HCC 55 for substance use disorder, HCC 48 for coagulation defects and other specified haematological disorders, and HCC 88 for angina pectoris. It alleges the codes were not clinically accurate, not supported by the medical record, or did not affect patient care.
- Monogram provides in-home care to Medicare Advantage beneficiaries under contracts with Medicare Advantage Organisations. It does not bill CMS. DOJ states that risk-sharing arrangements gave Monogram a financial incentive to submit additional diagnosis codes, because higher beneficiary risk scores raised the capitated payments CMS made to the plans.
- The case began as a qui tam action by Dr Ajay Gupta, a physician formerly employed by Monogram, filed in the Central District of California as case 2:22-cv-08758. He receives approximately $380,000. DOJ states the claims are allegations only with no determination of liability.
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The number is small enough to scroll past and the defendant is the reason not to. This settlement is not with a health plan. It is with the in-home vendor that supplied the codes, sitting two steps away from the federal payment.
- Enforcement moved down the supply chain. Monogram never submitted a claim to CMS across the 3 years at issue. The theory is causing submission, which reaches a contractor whose codes travel through an MAO before any federal money moves. Every vendor running in-home assessments under an MAO contract now sits inside that perimeter.
- DOJ named the contract structure itself as the incentive. The release states plainly that risk-sharing arrangements gave Monogram a financial reason to submit additional diagnosis codes. That structure is the norm across value-based in-home assessment, so the characterisation carries further than the $2.4 million.
- The four HCCs are a checkable audit list. 21, 55, 48 and 88 are high-weight categories that a home visit can capture easily and a chart can struggle to substantiate. Anyone holding risk-adjustment exposure should reconcile those four against documentation before someone else does.