Three days ago, the Department of Justice announced that Monogram Health — a Tennessee-based company that provides in-home care to Medicare Advantage beneficiaries — agreed to pay $2.4 million to settle allegations that it added diagnosis codes to patient records that weren't clinically accurate, in order to increase what Medicare paid. Most coverage of this story has focused on the money and the legal mechanics. What's gotten less attention is the part that actually matters to a Medicare beneficiary: these weren't abstract billing entries. They were diagnoses attached to real people's real medical charts — the same charts future doctors, future insurers, and you yourself rely on.
📋Quick Summary
- Monogram Health agreed to pay $2.4 million, including about $1.4 million in restitution, to settle False Claims Act allegations.
- The government alleged the company added diagnosis codes for four conditions — malnutrition, substance use disorder, blood clotting disorders, and angina — that weren't supported by patients' actual medical records.
- This is a civil settlement; Monogram did not admit wrongdoing, which is standard in this type of resolution.
- The alleged conduct ran from January 2021 through December 2023.
- The practice is called "upcoding" — adding diagnoses to raise a patient's Medicare Advantage risk score, which increases what the government pays the plan.
- Unlike most fraud we've covered, upcoding doesn't cost you money directly — it can quietly alter your actual medical record.
- A former Monogram physician blew the whistle and will receive roughly $380,000 of the settlement.
- This case is a concrete example of exactly the practice CMS's expanding RADV audit program, covered in our 2027 Medicare rules coverage, is designed to catch.
How a Company Gets Paid More for a Diagnosis You May Not Have
To understand why this happened, it helps to understand how Medicare Advantage plans get paid in the first place — a mechanism most beneficiaries have never had reason to think about.
CMS pays Medicare Advantage Organizations a fixed monthly amount for each enrolled beneficiary. That amount isn't flat — it's adjusted up or down based on a risk model called the Hierarchical Condition Category system, which uses the diagnoses on file for each beneficiary to estimate how costly their care is likely to be. A beneficiary with diabetes, heart failure, and a mobility limitation is assigned a higher risk score than a beneficiary with no chronic conditions, and the health plan receives a correspondingly higher monthly payment to care for them.
Monogram provides in-home care to Medicare Advantage beneficiaries under contracts with several MAOs. According to the Justice Department, those contracts included a risk-sharing arrangement: Monogram was eligible to be paid more by the health plans when the beneficiaries in its care had higher risk scores, because the health plans themselves were receiving higher payments from CMS. That structure created a direct financial incentive to document additional diagnoses — the more complex a patient looked on paper, the more everyone up the chain got paid.
The government alleged Monogram acted on that incentive between 2021 and 2023, submitting diagnosis codes within four specific categories — protein-calorie malnutrition (HCC 21), substance use disorder (HCC 55), coagulation defects and other specified hematological disorders (HCC 48), and angina pectoris (HCC 88) — that investigators say were not clinically accurate, not supported by documentation in patients' medical records, and in many cases did not affect how the patient was actually treated. Assistant Attorney General Brett Shumate framed the core issue plainly: "When companies submit false diagnosis codes, they unlawfully exploit a system built to support vulnerable seniors."
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Sources: DOJ Office of Public Affairs — Monogram Health settlement; Healthcare Dive — Monogram Health upcoding allegations.
Most Medicare fraud we write about tries to take money directly from you or from Medicare on a specific claim. Upcoding works differently: the diagnosis itself gets written into the medical record system, potentially becoming part of the clinical history that future providers, insurers, and even you may rely on.
An inaccurate diagnosis sitting in your chart isn't just a data problem. A "substance use disorder" or "malnutrition" diagnosis that was never clinically real can affect how future providers interpret your symptoms, what they screen for, and in some cases what coverage decisions get made down the line. If you've received in-home care through a Medicare Advantage plan in recent years, it's worth requesting a copy of your medical records and reviewing the diagnosis list for anything that doesn't match conditions you actually know you have or have been treated for.
Why This Connects Directly to What's Coming in 2027
This settlement isn't an isolated incident — it's a specific, resolved example of the exact practice that federal regulators have been ramping up enforcement against, and that pattern is set to intensify in 2027.
As we covered in our recent look at the finalized 2027 Medicare Advantage rules, CMS has announced plans to significantly expand its Risk Adjustment Data Validation audit program — moving from a sample of roughly 60 Medicare Advantage plans reviewed per year to auditing all eligible MA contracts. RADV audits exist specifically to catch the pattern alleged in the Monogram case: diagnosis codes submitted to inflate risk scores without adequate clinical support in the patient's actual records.
Monogram itself is not a Medicare Advantage Organization — it's a contracted care provider working with several MAOs — but the underlying incentive structure the DOJ described is the same one government watchdogs have flagged for years as a major driver of Medicare Advantage overpayment industry-wide. The Medicare Rights Center has specifically noted that this kind of overpayment doesn't just affect the specific plans involved; it raises costs across the entire Medicare program, including for beneficiaries on Original Medicare who have no relationship with the health plans in question, because it feeds directly into the trust-fund pressure behind projected future premium increases.
The whistleblower dimension is also worth noting for what it says about how these cases typically surface. The lawsuit was filed by Dr. Ajay Gupta, a physician formerly employed by Monogram, under the qui tam provisions of the False Claims Act, which allow private individuals with knowledge of fraud against the government to file suit on the government's behalf and receive a share of any recovery — in this case, roughly $380,000. Physicians and other clinical staff are frequently the first to notice when diagnosis codes don't match what they actually observed and documented for a patient.
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Sources: Justice Department — Central District of California; Medicare Rights Center — MA payments rising again in 2027.
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✅What This Means For You
If you've received in-home care through a Medicare Advantage plan since 2021: This settlement specifically involved in-home care visits, which are a common setting for the kind of chart review that can add diagnosis codes. Requesting your medical records and reviewing the diagnosis history is a reasonable, low-effort check — not because something is necessarily wrong, but because it costs you nothing to look.
If you're already on Medicare Advantage: This case doesn't affect your coverage or your costs directly. It's worth knowing about because it illustrates a structural incentive that exists across the industry, not just at one company — and it's part of why CMS is expanding audit activity heading into 2027.
If IRMAA affects you: Not directly connected. But the broader pattern of MA risk-score inflation described here is part of the same overpayment dynamic that pressures Medicare's overall finances, which indirectly shapes future premium and IRMAA trends.
If you're on Original Medicare: You're not directly exposed to Medicare Advantage risk-score practices, since Original Medicare doesn't use this payment model. But as the Medicare Rights Center has noted, industry-wide MA overpayment affects the trust funds that Original Medicare draws on too.
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How to Actually Check Your Own Record
If this story has you wondering whether your own chart might contain something similar, the process to check is more accessible than most people realize.
Request your medical records directly from any provider who has treated you, including any in-home care company contracted through your Medicare Advantage plan. Under federal law (HIPAA), you have the right to request and receive a copy of your medical records, generally within 30 days, and providers cannot refuse a reasonable request. Many providers now offer this through an online patient portal, which makes the request nearly instant.
Review the diagnosis or "problem list" section specifically. Look for any condition listed that you don't recognize, weren't told about, or don't believe you've ever been evaluated for. It's worth cross-referencing against your own memory of what any given visit actually covered — a diagnosis that appears with no corresponding visit note, test result, or conversation you remember is worth questioning.
If you find something that looks wrong, you have a formal right to request a correction. Under HIPAA's amendment provisions, you can submit a written request asking a provider to correct or amend information in your record that you believe is inaccurate. The provider must respond, and if they decline, they're required to explain why and document your disagreement in the file regardless.
You can also review your Medicare claims history directly through your Medicare.gov account, which shows what's been billed under your Medicare number — a useful cross-check against your provider's own chart.
If you believe something in your record reflects the kind of pattern described in this settlement, rather than a simple clerical error, you can report it to the HHS Office of Inspector General, which investigates exactly this category of Medicare Advantage fraud, or discuss it with your state's Senior Medicare Patrol program, which provides free help navigating exactly these situations.
None of this requires assuming something is wrong. It's simply worth knowing you have the right to look — and that looking is free and comparatively easy.
Related: Is Medicare Really Calling You in 2026 — Or Is It a Scam? and find your state's Senior Medicare Patrol for free fraud help
📊The Monogram Health Settlement at a Glance
The Bigger Picture on Upcoding Enforcement
This settlement is one data point in a broader enforcement trend that's been building for several years and shows no sign of slowing.
Upcoding investigations have targeted a range of players across the Medicare Advantage ecosystem — not just contracted care providers like Monogram, but the health plans themselves. Several of the largest national Medicare Advantage insurers have faced their own government scrutiny over risk-score practices in recent years, and the pattern DOJ described in the Monogram case — a financial incentive structure that rewards more diagnoses regardless of clinical accuracy — exists, in some form, across much of the industry's risk-sharing contracts.
What makes enforcement genuinely difficult is that the practice sits in a gray zone that's hard to police in real time. A diagnosis code isn't inherently fraudulent — Medicare Advantage's entire payment model depends on accurately capturing how sick beneficiaries actually are, and under-diagnosing is also a real problem that leaves patients under-treated. The line between legitimate, thorough clinical documentation and coding specifically designed to inflate a risk score is often only visible in hindsight, through exactly the kind of pattern analysis and whistleblower reporting that surfaced in this case.
That's precisely why the RADV audit expansion matters heading into 2027. Auditing a sample of 60 plans a year can catch only a fraction of this kind of pattern; auditing every eligible contract is a meaningfully different level of scrutiny, and settlements like this one are likely to become more common, not less, as that expanded program comes online.
For beneficiaries, the practical takeaway isn't alarm — it's awareness. Your medical record is yours to review, correct, and question, regardless of what's happening at the policy level. That right existed before this settlement and doesn't depend on any enforcement action to use.
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Sources: DOJ Office of Public Affairs; Healthcare Dive; WSMV Nashville.
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