Jacksonville, Fla.-based Complete Health agreed to pay $14.1 million in a settlement to resolve claims that it violated the False Claims Act to increase Medicare Advantage program payments.
The settlement resolves allegations from 2020 to 2023 that the company submitted diagnoses within two Hierarchical Condition Codes (HCC) that were incorrect, according to an Aug. 3 U.S. Department of Justice (DOJ) press release.
The HCCs—related to drug and alcohol dependence and mental health disorders—were not clinically valid, not properly supported by beneficiary medical records and/or not considered in the beneficiary’s care, management or treatment, the DOJ said.
Moreover, the system allegedly prompted physicians to add diagnosis codes even in instances where codes were “unsubstantiated or not clinically justified,” the release said. There has been no determination of liability, and the settlement resolves allegations in the claims.
“Health care fraud enforcement has long been a cornerstone of the mission of this office,” said Gregory Kehoe, U.S. Attorney for the Middle District of Florida, in a statement. “This settlement sends a strong message to our district, its residents, and medical providers doing business here, that our focus on this vital practice area has not wavered.”
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