Health Law Daily Wrap Up, BILLING AND CODING—SETTLEMENT AGREEMENTS: In-home health provider will pay $2.4 million to settle Medicare Advantage false coding claim, (Aug 28, 2026)

By Steven Melendez

The provider allegedly submitted false codes to boost Medicare Advantage payments.

Monogram Health Professional Services PC and Monogram Health Inc. (collectively Monogram) agreed to pay roughly $2.4 million to settle allegations by the Department of Justice that they violated the False Claims Act by submitting false diagnosis codes for patients to increase payments from Medicare Advantage insurers. “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” (Settlement Agreement, U.S. ex rel. Dr. Gupta v. Monogram Health Prof. Servs., No. 2:22-cv-8758-MWF-JC (C.D. Cal. Aug. 17, 2026)).

Medicare Advantage allows Medicare beneficiaries to opt out of traditional Medicare and into private health plans from insurers known as Medicare Advantage Organizations. The Centers for Medicare and Medicaid Services (CMS) pays MAOs a fixed amount for each beneficiary, with monthly payments adjusted based on per-patient risk factors. These risk factors are determined by a mathematical model that takes into account diagnoses reported by healthcare providers so that, in general, sick patients who are expected to require more expensive care generate higher payments to the MAOs.

Monogram provides in-home health care and related services to patients enrolled with certain MAOs. Those MAOs pay more to Monogram for patients with higher risk scores, which the Justice Department alleges gave Monogram an incentive to submit more diagnosis codes for patients to boost their scores.

The settlement resolves allegations that from Jan, 1, 2021 through Dec. 31, 2023, Monogram knowingly submitted false diagnosis codes for patients, including HCC 21 (Protein-Calorie Malnutrition), HCC 55 (Substance Use Disorder); HCC 48 (Coagulation Defects and Other Specified Hematological Disorders), and HCC 88 (Angina Pectoris). This led to higher payments to MAOs from CMS than would have otherwise been paid out.

“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 (HHSOIG). “This settlement underscores HHSOIG’s commitment to protecting the integrity of taxpayerfunded federal health care programs. Medicare Advantage exists to deliver medically necessary care to beneficiaries, not to serve as a vehicle for improper financial gain.”

A physician who formerly worked for Monogram initially filed the case as a qui tam matter in 2022. He will receive $386,225 through the settlement.

The agreement resolves claims under the False Claims Act, Civil Monetary Penalties Law, and Program Fraud Civil Remedies Act, though it does not resolve liability under the Internal Revenue Code, “any criminal liability,” or “any administrative liability or enforcement right, including mandatory or permissive exclusion from Federal health care programs,” according to the settlement agreement.

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