DOJ Continues Crackdown on Medicare Advantage Risk Adjustment
A recent $14.1 million False Claims Act settlement is the latest in a series of DOJ enforcement actions targeting Medicare Advantage organizations and their vendors for improper diagnosis coding practices.
The Department of Justice is escalating its scrutiny of Medicare Advantage (MA) risk-adjustment coding, evidenced by a series of major False Claims Act (FCA) settlements. The latest involves a $14.1 million agreement with Complete Health Partners Holdings to resolve allegations it pressured providers to add unsupported diagnosis codes into patient electronic medical records to inflate risk scores and payments. This follows other recent nine-figure settlements against a health system, a national insurer, and an in-home assessment vendor for similar practices. Sophisticated clients in the MA ecosystem—including plans, provider groups, and their vendors—should take note of this clear enforcement priority. The DOJ is targeting programs that suggest diagnosis codes, particularly when those suggestions are not substantively reviewed by providers or lack clinical support. Compounding the risk, new OIG guidance expressly identifies EMR prompts for risk-adjusting diagnoses as potentially fraudulent. Affected organizations should re-evaluate their coding suggestion programs, incentive structures, and documentation protocols to ensure they prioritize and can demonstrate clinical accuracy.