Complete Health: Coder Prompts and Unsupported Diagnoses
In the Complete Health risk adjustment settlement, Complete Health Partners Holdings agreed to pay $14,100,000 to resolve allegations that unsupported diagnoses increased Medicare Advantage payments. The alleged operation connected coders reviewing charts, doctors asked to add diagnoses and health plans sharing the resulting revenue with the company.
The Justice Department announced the settlement on August 3, 2026. Complete Health is a management services organization headquartered in Jacksonville, Florida, managing, owning or operating provider groups in Florida, Alabama and Colorado. The case concerns diagnosis coding inside physician practices and the financial arrangement that made those diagnoses valuable beyond the examination room.
How Medicare Advantage Payments Reached Complete Health
Medicare Advantage risk adjustment changes what a health plan receives according to the expected cost of caring for its members. The Centers for Medicare & Medicaid Services pays plans a fixed monthly amount for each beneficiary, adjusted for risk factors. Its Hierarchical Conditions Category model uses diagnoses reported by healthcare providers, with more severe conditions generally producing higher risk scores and higher payments.
Complete Health’s contracts gave it a percentage of the payments the plans received from CMS. The government alleged that the disputed diagnoses increased payments to the plans, which then passed a portion of that increase to Complete Health. The diagnosis moved toward the government. A share of the money came back to the management company.
A diagnosis can increase a plan’s risk-adjusted payment without increasing the fee for an office visit. We follow the diagnosis through the plan and the payment-sharing contract, because the visit charge alone can miss the money at issue.
What the Government Alleged About the Coding
The allegations covered HCC 55, drug and alcohol dependence, and HCC 59, major depressive, bipolar, and paranoid disorders, during 2020 through 2023. The government said Complete Health submitted diagnoses that were clinically invalid, lacked proper support in the medical records or were not considered in the patient’s care, management or treatment.
According to the Justice Department’s account, Complete Health distributed incorrect coding guidance to coders and physicians. Coders reviewed patients’ records for additional chronic-condition diagnoses, including diagnoses in those categories. The company then prompted doctors to add codes even when the diagnoses were unsubstantiated or clinically unjustified, and the doctors added inaccurate codes.
The alleged pressure therefore began before the final diagnosis reached the plan. The guidance shaped what coders looked for, and the prompt asked a doctor to put the result into the record. We see the absurdity in that allegation: a diagnosis could matter to the payment without mattering to the patient’s care.
For a health care professional, the question is concrete: what did the patient record support, and what did the coding request ask you to add? For a coder, it includes who supplied the instruction and how it treated clinical support. Those accounts connect the company’s alleged guidance to the diagnosis actually submitted.
The Whistleblower Saw the Health-Plan Side
The whistleblower was a former associate director of risk adjustment at VIVA Health. She brought the False Claims Act case, and the United States later joined part of it for settlement. Her role puts a health-plan employee inside this story of diagnoses originating in physician practices.
A management services organization supplies contracted administrative functions while the professional entity supplies clinical services. That division helps explain why relevant knowledge can sit in different places: with the person who documented the encounter, the team handling diagnosis data and the people who understand the payment contract. A plan employee’s account can connect the submitted codes with the revenue they affected.
What Evidence Does a Whistleblower Need?
For a case about diagnosis prompts and shared Medicare payments, the useful evidence connects the coding instruction, the clinical record, the submitted diagnosis and the payment contract. Our work with records that should agree follows those connections. A prompt explains what someone wanted added, the chart shows its clinical support, and submission records show whether the diagnosis entered the payment process. In the DaVita Medical Holdings settlement, the government alleged that one-way chart reviews added missed diagnoses while ignoring inaccurate codes that should have been removed.
The contract answers a further question: how did the plan’s payment affect the practice or management company? We examine that relationship alongside the coding decisions, including what happened when someone questioned a diagnosis. If you saw the instruction or reviewed the disputed code, your account can explain a decision that the final payment data does not show.
How Much of a Settlement Does a Whistleblower Get?
A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In Complete Health’s case, the Justice Department announced that the former health-plan employee would receive approximately $2.47 million as her share of the federal recovery.
You Know Why the Diagnosis Was Added
If you worked with the coding prompts, clinical records or plan payments, speak to our whistleblower experts about what you saw. We build the case with you around the diagnosis, the instructions behind it and the money it changed, and bring in Medicare Advantage whistleblower lawyers who understand practice and health-plan records. We stay beside you as your inside knowledge becomes the foundation of your whistleblower case.
