Monogram Health Settles $2.4M Medicare Fraud Case

A Nashville-based company that provides in-home care to Medicare Advantage patients has agreed to pay $2.4 million to resolve federal allegations that it caused false claims to be submitted to the government healthcare program. Monogram Health struck the civil settlement with the Department of Justice over diagnosis codes federal officials say were not clinically accurate, not supported by patient records, or had no bearing on how patients were actually treated.

According to WSMV, federal officials allege Monogram had a financial incentive to report additional diagnoses for its patients, since higher patient risk scores can translate into higher Medicare payments to the Medicare Advantage health plans the company contracts with. Officials say Monogram's coding practices increased those risk scores, which in turn led to bigger payments flowing through the Medicare Advantage program. The Department of Justice says the settlement resolves civil False Claims Act allegations covering Monogram's conduct from 2021 through 2023.

The DOJ alleged the company knowingly submitted unsupported diagnosis codes across four specific Hierarchical Condition Categories during that period: protein-calorie malnutrition, substance use disorder, coagulation and blood disorders, and angina pectoris. Those four categories are among the diagnostic groupings federal auditors frequently flag as vulnerable to improper billing, per the DOJ's account of the case. Federal prosecutors alleged Monogram's risk-sharing contracts with Medicare Advantage Organizations entitled the company to a share of higher monthly CMS payments whenever patients carried elevated risk scores, creating what the Washington Times described as a direct financial incentive to submit inflated codes.

A Whistleblower Physician's Payout

The case traces back to a lawsuit filed under seal in December 2022 in the U.S. District Court for the Central District of California by Dr. Ajay Gupta, a former Monogram physician. As the whistleblower who brought the qui tam action, Gupta will receive approximately $380,000 as his share of the $2.4 million recovery, the Justice Department says. Qui tam provisions of the False Claims Act allow private individuals to sue on behalf of the federal government and collect a percentage of whatever is recovered.

Assistant Attorney General Brett A. Shumate said in a Justice Department statement, reported by the Washington Times, that the settlement reinforces the government's commitment to ensuring Medicare Advantage payments are based on accurate clinical information. As reported by Becker's Healthcare, the settlement resolves civil allegations only, and Monogram made no admission of legal liability as part of the agreement.

A Company Built on Insurer Backing

Founded in 2019 and headquartered in Brentwood, Tennessee, Monogram Health provides in-home chronic condition management for Medicare Advantage beneficiaries. The company raised $375 million in a Series C funding round in January 2023 from investors that included Cigna, CVS Health, and Humana, according to PitchBook — the same kinds of major insurers that also enter risk-sharing arrangements with the company for patient care.

This isn't the only legal scrutiny Monogram has faced recently. In June, a former market manager filed a whistleblower retaliation lawsuit against the company, Hoodline previously reported, alleging she was terminated in November 2025 after raising concerns about the company's hospital visitation practices. That case, filed under Florida whistleblower and family medical leave laws, remains separate from the federal False Claims Act settlement announced this week.

Part of a Broader Federal Crackdown

Monogram's settlement lands amid a wave of federal enforcement actions targeting Medicare Advantage risk-adjustment coding. Just three weeks earlier, on August 3, the DOJ announced a $14.1 million False Claims Act settlement with primary care management organization Complete Health over similar allegations of unsupported diagnosis coding. In February, the Department of Health and Human Services Office of Inspector General issued its first Medicare Advantage-specific compliance program guidance since 1999, a signal of intensified federal oversight of risk-adjustment practices industry-wide.

The stakes for that oversight are considerable. As of 2025, Medicare Advantage surpassed 50% of total Medicare enrollment nationwide, with more than 30 million seniors enrolled in private plans that receive risk-adjusted capitation payments. Those payments, calculated using diagnostic categories like the ones cited in Monogram's case, determine how much the Centers for Medicare & Medicaid Services pays health plans each month based on patient risk scores.

Compared to some of the larger settlements to emerge from this enforcement push, Monogram's $2.4 million is modest. Hoodline has previously covered Kaiser Permanente's $556 million risk-adjustment settlement and a $62 million settlement involving Seoul Medical Group, both tied to similar allegations of inflated diagnostic coding submitted to Medicare Advantage. Together, the cases point to a pattern of regulators pursuing not just insurance carriers but the care management vendors and risk-sharing intermediaries that operate underneath them.