Monogram Health: Four HCCs and a Share of the Higher Payment

Monogram Health agreed to pay $2.4 million in a Medicare Advantage settlement over alleged unsupported diagnosis coding to increase payments. A physician who had worked for the in-home care provider brought the whistleblower case. The diagnoses helped determine what the health plan received, and Monogram’s contracts let it share in the higher payment. Someone inside the practice could see the patient behind the code.

The Justice Department announced the agreement on August 24, 2026. Monogram, headquartered in Tennessee, provided in-home care and related services to Medicare beneficiaries through contracts with Medicare Advantage organizations.

The Four HCCs Behind the Allegations

The alleged HCC coding problems ran from January 1, 2021 through December 31, 2023 and involved four diagnosis categories:

1. HCC 21: Protein-Calorie Malnutrition.
2. HCC 55: Substance Use Disorder.
3. HCC 48: Coagulation Defects and Other Specified Hematological Disorders.
4. HCC 88: Angina Pectoris.

The government alleged that Monogram knowingly submitted codes in these categories that were clinically inaccurate, lacked support in the patient’s medical record, or did not require or affect patient care, treatment or management. Those codes allegedly inflated the beneficiaries’ risk scores and caused Medicare to pay the plans more than it would have paid without them.

The visit note can show what the clinician actually recorded, while the coding record shows what the organization turned that encounter into. The code travels to the plan, but its support starts with the patient.

Why Risk Sharing Mattered to Monogram

Monogram’s risk-sharing contracts made higher beneficiary risk scores financially valuable to the provider. According to the Justice Department, Monogram was eligible for higher payments from the plans when those plans received more from Medicare for the patients in Monogram’s care.

The original complaint also named Cigna and Humana, while the announced settlement covered Monogram.

The path from diagnosis to payment begins with the plan’s monthly payment for an enrolled beneficiary. The Centers for Medicare & Medicaid Services adjusts that payment for expected health costs. As HHS-OIG explains, diagnoses feed into HCCs, which group clinically related conditions. Their weights contribute to the beneficiary’s risk score alongside demographic factors, and the score multiplies the plan’s base payment rate.

That is why a provider’s diagnosis can have financial consequences beyond the bill for the visit. The plan receives the federal payment, and the provider’s contract determines how that revenue reaches the practice. In Monogram’s case, the government expressly identified this arrangement as an incentive to submit additional diagnosis codes. The alleged unsupported codes were valuable on both sides of the provider-plan relationship. The government alleged that taxpayers funded the increase.

The 2015 working paper Upcoding or Selection? Evidence from Medicare on Squishy Risk Adjustment, hosted by Duke University, describes how insurers can carry the payment incentive into a physician’s compensation by paying for the codes physicians assign instead of the visits and procedures they perform.

The paper describes insurers influencing coding before, during and after an encounter through payment contracts, templates carrying prior diagnoses, training for coding staff and reviews of submitted claims. The incentive can reach the record through several people before a diagnosis becomes a federal payment input.

The study estimated that private Medicare plans generated diagnosis-based risk scores 6% to 16% higher than the same enrollees would have generated under traditional Medicare. Its analysis separated differences in coding from differences in who enrolled. It also found that coding intensity increased with closer insurer-provider integration.

That finding gives an insider a reason to look beyond the final diagnosis file. The contract can explain why an organization wants more codes, while the medical record shows what supports them. Monogram’s alleged conduct sits at that intersection: a financial incentive tied to the provider’s contracts and diagnoses the government said lacked the required clinical basis.

The Physician Inside the Provider

The whistleblower, a physician formerly employed by Monogram, brought the qui tam case under the False Claims Act. That role matters because an employed physician may see the clinical encounter, the resulting record and the organization’s expectations about diagnosis coding from inside the same practice.

A whistleblower case under the False Claims Act can pay a whistleblower reward of 15% to 30% of what the government recovers.

The Justice Department credited Monogram for cooperating in a case brought by its own former physician.

Complete Health Shows Another View of Provider Coding

Complete Health agreed to pay $14.1 million in a far larger provider coding settlement. The management services organization managed, owned or operated affiliated provider groups. The Justice Department alleged that it gave incorrect coding guidance and prompted doctors to add diagnoses that were unsupported or clinically unjustified.

That case concerned drug and alcohol dependence and major depressive, bipolar and paranoid disorders. The alleged workflow made the provider’s role concrete: coding guidance reached doctors, prompts sought additional diagnoses, and the doctors added inaccurate codes. The whistleblower was a former associate director of risk adjustment at VIVA Health, a health plan.

The comparison puts different jobs along the payment chain in view. Complete Health’s case began with a plan’s risk-adjustment professional. Monogram’s began with a physician employed by the provider. A healthcare whistleblower may recognize the problem in the patient encounter or in the diagnosis data reaching the insurer. Both perspectives can connect clinical information to a payment the government should not have made.

The Encounter, the Code and the Contract

For an insider who recognizes Monogram’s alleged pattern, the useful evidence connects the patient’s record to the submitted diagnosis and the provider’s financial incentive. We examine how the clinical account became a code, how that code reached the plan and what the organization’s decision-makers knew about its support.

The details depend on where you worked in health care. A physician may know which condition was assessed and how it affected care. A coding employee may know what instructions accompanied the encounter record. A contracting or finance employee may understand the payment terms. Compliance staff may have seen objections and the response to them. Those perspectives can explain a decision that looks like a bare diagnosis code from outside the organization.

The provider’s contract and the clinician’s record describe different sides of the same payment.

You Know the Patient Behind the Code

If you saw diagnosis coding pull away from the care your practice delivered, talk with our whistleblower experts. We build the case around your clinical and business knowledge, bring in Medicare Advantage whistleblower lawyers who understand provider risk-sharing arrangements, and stand with you through the pursuit of a recovery.