Medicare Advantage Provider Complete Health to Pay $14.1 Million to Settle False Claims Act Allegations

Complete Health Partners Holdings, a Jacksonville-based management services organization that manages provider groups across Florida, Alabama, and Colorado, has agreed to pay $14.1 million to resolve allegations that it violated the False Claims Act by submitting false diagnosis codes to inflate payments from the Medicare Advantage program. Under Medicare Advantage, also known as Medicare Part C, beneficiaries enroll in private health plans and the Centers for Medicare & Medicaid Services adjusts payments based on enrollees’ health status—sicker patients generate higher reimbursements.

The government alleged that between 2020 and 2023, Complete Health submitted diagnosis codes for Drug and Alcohol Dependence (HCC 55) and Major Depressive, Bipolar, and Paranoid Disorders (HCC 59) that were not clinically valid or supported by patients’ medical records.

The company allegedly disseminated incorrect coding guidance to its coders and physicians, then prompted doctors to add unsubstantiated diagnoses—which the doctors did, leading to inflated risk scores and higher CMS payments. Because Complete Health received a percentage of CMS payments under “risk sharing” compensation arrangements with the Medicare Advantage plans, the company had a direct financial incentive to inflate diagnosis codes.

The settlement resolves a qui tam whistleblower lawsuit filed by Karen Bowers, former Associate Director of Risk Adjustment at VIVA Health. Under the False Claims Act, Bowers will receive approximately $2,467,500 as her share of the federal recovery. This case reflects the government’s sustained commitment to combating Medicare Advantage fraud and holding accountable those who attempt to improperly profit at taxpayer expense.