JACKSONVILLE, Fla. – Complete Health Partners Holdings has agreed to pay $14.1 million to settle allegations that it caused false diagnosis codes to be submitted to boost payments from the Medicare Advantage program, the Department of Justice said.
The government says the company, which manages affiliated provider groups in Florida, Alabama and Colorado, pushed coders and doctors to add diagnosis codes for conditions in Hierarchical Condition Category 55 (drug and alcohol dependence) and HCC 59 (major depressive, bipolar and paranoid disorders) from 2020 to 2023.
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Prosecutors allege many of those codes weren’t clinically valid, weren’t supported by medical records and weren’t part of the patients’ care.
The DOJ said Complete Health had contracts that let it receive a share of the money Medicare Advantage plans got from the Centers for Medicare & Medicaid Services. That “risk-sharing” setup gave the company a financial incentive to increase patients’ risk scores — and the payments tied to them — by adding diagnosis codes.
Here’s how Medicare Advantage payments work in plain terms: private plans get a fixed monthly amount for each enrollee, but that payment is adjusted based on a risk model that uses diagnoses reported by providers. Sicker patients typically generate higher payments. The government says the added codes raised risk scores and led to bigger payments, some of which were passed on to Complete Health.
U.S. Attorney Gregory W. Kehoe said the settlement shows the office remains focused on health care fraud enforcement.
“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,” he said.
Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division said the agreement reflects the department’s commitment to protect taxpayer money and ensure Medicare payments are based on accurate information. A senior official at the Department of Health and Human Services Office of Inspector General added that companies that improperly boost profits by reporting bogus conditions will be held responsible.
The settlement resolves a whistleblower suit brought under the False Claims Act by a former risk-adjustment official at VIVA Health. Under that qui tam provision, a private party can sue on behalf of the government and receive a portion of any recovery.
The suit is captioned United States ex rel. Karen Bowers v. Complete Health Partners, Inc., et al., Civil Action No. 3:22-cv-463 (M.D. Fla.). Karen Bowers will receive about $2,467,500 as her share of the federal recovery, the Justice Department said.