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Getting the latest healthcare news for you
Getting the latest healthcare news for you
A home health company is paying up for gaming Medicare. Monogram Health agreed to pay $2.4 million to settle DOJ allegations that it inflated diagnostic codes to boost reimbursements through Medicare Advantage contracts with Cigna and Humana from 2021 to 2023. The case, triggered by a whistleblower suit, is part of a broader federal crackdown on upcoding in the Medicare Advantage program.
A home health company is paying up for gaming Medicare. Monogram Health, a Tennessee-based provider of in-home care for patients with complex and chronic conditions, has agreed to pay $2.4 million to settle DOJ allegations that it submitted clinically unsupported diagnosis codes to inflate risk scores — and, in turn, reimbursements — under Medicare Advantage contracts with Cigna and Humana between 2021 and 2023.
The case was triggered by a whistleblower suit filed by Dr. Ajay Gupta, a former Monogram nephrologist and regional medical director. The alleged codes — covering conditions like protein-calorie malnutrition, substance use disorder, and angina — were either inaccurate or not supported by patients' medical records, causing CMS to overpay Medicare Advantage plans. Gupta will receive $386,225 from the recovery under the False Claims Act's whistleblower provisions.
By the Numbers:
Why it matters: This settlement is part of an intensifying federal crackdown on Medicare Advantage fraud. As CMS accelerates audits of health plans and overpayments balloon into the tens of billions, providers and insurers face growing scrutiny over risk-score manipulation — a systemic issue with major implications for healthcare spending.
