Medicare Advantage Provider Monogram Health Pays $2.4M to Settle False Claims Act Whistleblower Suit

Monogram Health Professional Services PC and Monogram Health Inc., a Tennessee-based in-home care provider, have agreed to pay $2.4 million to resolve allegations that they violated the False Claims Act by submitting false diagnosis codes to inflate payments from the Medicare Advantage program. The settlement resolves claims that between January 2021 and December 2023, Monogram knowingly submitted diagnosis codes that were not clinically accurate, not supported by patients’ medical records, and did not require or affect patient care.

The government alleged that Monogram submitted unsupported codes under four specific Hierarchical Condition Categories (HCCs): protein-calorie malnutrition, substance use disorder, coagulation defects, and angina pectoris. Because Monogram held risk-sharing contracts with Medicare Advantage Organizations, inflated risk scores directly translated into higher capitated payments from the Centers for Medicare & Medicaid Services. Approximately $1.4 million of the settlement represents restitution.

The case originated from a qui tam whistleblower lawsuit filed by Dr. Ajay Gupta, a physician formerly employed by Monogram, who will receive approximately $380,000 as his share of the recovery under the False Claims Act’s whistleblower provisions. This case reflects the government’s sustained focus on Medicare Advantage risk adjustment fraud and the critical role healthcare insiders play in exposing billing schemes that exploit taxpayer-funded programs. Individuals with knowledge of similar healthcare fraud or improper diagnosis coding practices are encouraged to consult experienced whistleblower attorneys to explore potential False Claims Act remedies.