Monogram Health agrees to $2.4 million settlement over Medicare Advantage diagnosis codes
Sep 27, 2026 edition · GC-2026-0004 · Published 2026-09-27 · Version 2 · Settled
Monogram’s $2.4 million resolution concerns four diagnosis categories submitted under in-home Medicare Advantage risk-sharing arrangements. DOJ describes clinical accuracy, documentation and relevance to care during 2021–2023, credits cooperation and provides a whistleblower share. The allegations were not adjudicated.
What happened
On August 24, DOJ announced that Monogram Health Professional Services PC and Monogram Health Inc., headquartered in Tennessee, agreed to pay $2.4 million to resolve False Claims Act allegations. Monogram provided in-home care and related services under contracts with Medicare Advantage organizations. Those risk-sharing arrangements made higher beneficiary risk scores financially relevant to both plan payments from CMS and Monogram’s reimbursement. The alleged conduct occurred from January 1, 2021 through December 31, 2023 and concerned codes that were clinically inaccurate, unsupported in the medical record and/or did not require or affect patient care, treatment or management.
The release identifies four Hierarchical Condition Categories: protein-calorie malnutrition, substance use disorder, coagulation defects and other specified hematological disorders, and angina pectoris. It explains that unsupported diagnoses can inflate risk scores and capitated payments without establishing an additional service-based entitlement. The settlement also resolves a former Monogram physician’s whistleblower action; DOJ says the relator will receive approximately $380,000 and that Monogram received cooperation credit. The announcement establishes the reported resolution, not a separately verified execution or completed-payment date. DOJ expressly states that the claims remain allegations and liability has not been determined.
Scope and timing
- Authority status
- Settled
- Applicability
- Operationally relevant
- Audience
- Health systems, Provider networks
- Jurisdiction
- Federal, California
Why it matters
The case concerns provider-generated diagnoses under risk-sharing contracts, so coding controls need to connect clinical documentation with the data sent to plans. The four named categories give audit teams a concrete scope rather than a general instruction to review risk adjustment.
Recommended action
Review responsibility for diagnosis accuracy under MA contracts. Sample the four named categories for encounter support, clinical accuracy and effect on care, and document how errors are communicated to plans and evaluated for correction. Treat this as a case-based audit recommendation, not a finding against another provider.
Case details
- agencies
- U.S. Department of Justice, U.S. Attorney Office, Central District of California
- entities
- Monogram Health Professional Services PC, Monogram Health Inc.
- action Type
- Settlement
- event Date
- 2026-08-24
- alleged Conduct
- Alleged inaccurate, unsupported and/or non-care-affecting diagnosis submissions in four HCCs during January 1, 2021 through December 31, 2023 under MA risk-sharing arrangements.
- resolution
- Agreement to pay $2.4 million, announced August 24, 2026, with approximately $380,000 stated for the whistleblower and cooperation credit. Exact execution and completed payment are not separately established; no liability determination.
Operational lessons
- Connect provider coding oversight with MA contract data obligations.
- Test record support, clinical accuracy and relevance to care in the four named categories.
- Retain correction and communication evidence; do not infer a CIA’s existence or absence from announcement silence.
Related coverage
Relevant to Medicare Advantage contracting and coding oversight in the payer product. Medicare & Medicaid →
Sources
- Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act SuitOfficial · U.S. Department of Justice, Office of Public Affairs · 2026-08-24 · Source review 2026-09-06
- Medicare Advantage Provider Monogram Health Agrees to Pay $2.4 MillionOfficial · U.S. Attorney Office, Central District of California · 2026-08-24 · Source review 2026-08-31
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