Tennessee-based in-home care provider Monogram Health has agreed to pay $2.4 million to settle allegations that it caused the submission of false diagnosis codes to boost Medicare Advantage payments.
From Jan. 1, 2021, through Dec. 31, 2023, Monogram allegedly knowingly submitted diagnosis codes that were not clinically accurate, not supported by patients’ medical records, or did not affect patient care, according to an Aug. 24 Justice Department news release.
The codes fell under four Hierarchical Condition Categories: protein-calorie malnutrition, substance use disorder, coagulation defects and angina pectoris. Because Monogram held risk-sharing contracts with Medicare Advantage Organizations, inflated risk scores translated into higher payments from CMS.
The settlement resolves a whistleblower lawsuit filed by Ajay Gupta, MD, a physician formerly employed by Monogram, according to the release. Dr. Gupta will receive about $380,000 of the recovery under the False Claims Act’s qui tam provisions.
The claims resolved by the settlement are allegations only and there has been no determination of liability, according to the release.
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