Jacksonville, Fla.-based management services organization Complete Health Partners Holdings has agreed to pay $14.1 million to settle allegations that it violated the False Claims Act by causing false diagnosis codes to be submitted to boost Medicare Advantage payments.
The settlement resolves allegations that between 2020 and 2023, Complete Health submitted diagnosis codes under Hierarchical Condition Categories 55 (drug and alcohol dependence) and 59 (major depressive, bipolar and paranoid disorders) that were not clinically valid or supported by patient records, according to an Aug. 3 Justice Department news release.
The Justice Department alleged Complete Health gave coders and physicians incorrect coding guidance and prompted doctors to add unsubstantiated diagnoses, which increased risk scores and the corresponding CMS payments passed on to Complete Health under its risk-sharing contracts with Medicare Advantage organizations.
The case originated from a whistleblower lawsuit filed by a former associate director of risk adjustment at VIVA Health, who will receive approximately $2.47 million from the settlement.
The Justice Department said that the claims resolved are allegations only, with no determination of liability.
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