DOJ Hits Medicare Advantage Providers With $558M+ in FCA Settlements
Three recent DOJ settlements totaling over $558 million target Medicare Advantage providers for allegedly causing false diagnosis codes, signaling heightened FCA scrutiny of risk-sharing arrangements.
DOJ announced three False Claims Act settlements against Medicare Advantage providers for allegedly causing the submission of unsupported diagnosis codes that inflated CMS risk-adjustment payments. The Villages Health agreed to pay $541.5 million—the largest of the three—after self-disclosing under the HHS-OIG Health Care Fraud Self-Disclosure Protocol and receiving substantial cooperation credit. Monogram Health paid $2.4 million and Complete Health paid $14.2 million; both matters originated in qui tam suits in which DOJ partially intervened. All three settlements featured risk-sharing arrangements that allegedly incentivized providers to inflate risk scores, expanding DOJ's enforcement lens beyond the Medicare Advantage plans themselves to their provider partners. Counsel advising MA plans, provider groups, and risk-bearing entities should evaluate diagnosis-coding controls, governance over value-based contracts, and the comparative benefits of proactive self-disclosure. The settlements come as DOJ's new National Fraud Enforcement Division signals continued prioritization of managed-care fraud, making this an active area to monitor for indictments, declinations, and additional resolutions.