Monogram Health Professional Services PC and Monogram Health Inc., collectively known as Monogram Health and headquartered in Tennessee, have agreed to pay $2.4 million to resolve allegations that they violated the False Claims Act by causing the submission of false diagnosis codes to increase payments under the Medicare Advantage program, the Justice Department announced.
The settlement covers conduct alleged to have occurred between Jan. 1, 2021, and Dec. 31, 2023. During that period, Monogram allegedly knowingly submitted diagnosis codes that were not clinically accurate, were not supported by documentation in beneficiaries’ medical records and/or did not require or affect patient care, treatment or management. The codes fell within four Hierarchical Conditions Categories: Protein-Calorie Malnutrition, Substance Use Disorder, Coagulation Defects and Other Specified Hematological Disorders, and Angina Pectoris, according to the Justice Department.
Under the Medicare Advantage program, the Centers for Medicare & Medicaid Services pays private health plans known as Medicare Advantage Organizations a fixed monthly amount for each enrolled beneficiary. Those payments are adjusted using a risk-based model that accounts for beneficiaries’ diagnosed health conditions. In general, MAOs receive higher payments for sicker beneficiaries expected to incur greater health care costs.
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