A Tennessee-based Medicare Advantage provider has agreed to pay $2.24 million to settle a lawsuit brought by the U.S. Department of Justice (DOJ) that accused the company of violating the False Claims Act.
Monogram Health, a home healthcare group that provides multi-specialty care to seniors covered by privatized Medicare Part C plans, was accused of submitting upcoded claims to insurers for reimbursement, which would ultimately be paid in part by the Centers for Medicare & Medicaid Services.
The DOJ alleges that from 2021 to 2023, the company filed claims for patients using inaccurate diagnosis codes in an effort to claim more funds than they were actually owed for the delivery of care to patients.
As a provider that billed Medicare plans, Monogram would be paid risk-adjusted payments for patients with chronic conditions. In many cases, the company cares for patients stuck at home who have multiple diseases, such as diabetes and chronic heart failure.
According to the DOJ, there was a documentation issue on these conditions that signaled potential wrongdoing. Authorities alleged that Monogram billed for patient care that was not supported by treatment plans for chronic conditions that patients did not actually have,
“When companies submit false diagnosis codes, they unlawfully exploit a system built to support vulnerable seniors,” Assistant Attorney General Brett A. Shumate of the DOJ’s Civil Division, said in a statement. “This settlement reinforces the Department’s...
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