Monogram Health Professional Services PC and its parent, Monogram Health Inc., headquartered in Brentwood, Tennessee, have agreed to pay $2.4 million to resolve allegations that they violated the False Claims Act by causing false diagnosis codes to be submitted to inflate their Medicare Advantage payments. The U.S. Attorney’s Office for the Central District of California announced the settlement August 24, 2026.
Monogram provides in-home care to Medicare beneficiaries enrolled in Medicare Advantage plans, working under contracts with the Medicare Advantage Organizations (MAOs) — the private insurers, such as UnitedHealthcare or Humana, that administer those plans — that pay Monogram more when the patients in its care carry higher “risk scores.” Those risk scores come from CMS’s Hierarchical Conditions Category model, which pays MAOs more for beneficiaries expected to need costlier care based on the diagnoses their providers report; a diagnosis must be documented from an actual face-to-face visit and must have affected the patient’s care at that visit to count. Because Monogram’s own contracts tied its revenue to those same risk scores, the government says the company had a direct financial incentive to report additional diagnoses that inflated them.
Monogram Health Inc. was reportedly founded in 2019 by CEO Michael Uchrin, with backing from Frist Cressey Ventures, the venture firm co-founded by former U.S. Senate Majority Leader and heart-transplant surgeon Bill Frist, who chairs Monogram’s board. The company built its business around in-home, “value-based” care for patients with chronic kidney disease and other overlapping chronic conditions — a model that pairs nephrologists, cardiologists, and other specialists to manage complex patients at home rather than in a clinic, using what the company describes as AI-driven care planning. Monogram grew quickly on the strength of five funding rounds totaling more than $540 million, culminating in a $375 million Series C round in December 2022 led by CVS Health Ventures, Cigna Ventures, Memorial Hermann Health System, and Pura Vida Investments, with additional participation from Humana, TPG Capital, and SCAN Health Plan — a roster that includes several of the very insurers whose Medicare Advantage plans Monogram contracts with. By 2026, industry trackers estimated the company’s annual revenue at roughly $2.2 billion and its footprint at more than 500 employees operating across some 34 states.
The settlement covers the period from January 1, 2021 through December 31, 2023 and resolves allegations that Monogram knowingly submitted diagnosis codes in four specific categories that were not clinically accurate, not supported by the patient’s medical records, or did not actually affect the care given at the visit: HCC 21 (protein-calorie malnutrition), HCC 55 (substance use disorder), HCC 48 (coagulation defects and other blood disorders), and HCC 88 (angina pectoris, a form of chest pain linked to heart disease). Those inflated risk scores, the government says, caused CMS to pay the MAOs more than it should have.
This settlement appears to be Monogram’s first public False Claims Act resolution, but it lands the company squarely inside a pattern of intense federal scrutiny of exactly this kind of Medicare Advantage risk-adjustment coding across the industry in 2025 and 2026. In March 2026, CVS Health’s Aetna unit agreed to pay $117.7 million to settle DOJ allegations that it ran a chart-review program paying coders to find additional diagnoses that boosted patient risk scores, including diagnoses unsupported by medical records. HHS-OIG audits have separately flagged similar “upcoding” concerns at other Medicare Advantage plans, including a 2025 finding against Coventry Health Care of Missouri. Congressional advisers at MedPAC have estimated that upcoding across the industry inflates Medicare Advantage payments by roughly 10% annually relative to traditional Medicare, and the Committee for a Responsible Federal Budget has projected the cumulative overpayment could approach $600 billion over the next decade if unaddressed — figures that help explain why DOJ’s new Task Force to Eliminate Fraud and National Fraud Enforcement Division have made Medicare Advantage risk-adjustment fraud a recurring enforcement target this year, with Kaiser Permanente, Humana, and UnitedHealth Group’s Optum unit all facing related scrutiny in recent years as well. Notably, several of Monogram’s own investors, including CVS and Humana, operate Medicare Advantage plans that could themselves face exposure if a downstream provider’s coding practices inflate the risk scores those plans report to CMS — illustrating how closely intertwined the incentives are across the value-based care ecosystem Monogram operates within.
The case originated as a whistleblower, or qui tam, lawsuit filed by Dr. Ajay Gupta, a physician formerly employed by Monogram, captioned United States ex rel. Dr. Ajay Gupta v. Monogram Health Professional Services, et al., No. 2:22-cv-08758 MWF-JCx, in the U.S. District Court for the Central District of California. Under the False Claims Act’s qui tam provisions, a private individual with knowledge of fraud against the government can file suit on the government’s behalf and share in any recovery; Dr. Gupta will receive approximately $380,000 of the $2.4 million settlement.
As is standard in False Claims Act settlements, DOJ’s release states plainly that the claims resolved are allegations only, and the settlement includes no determination of liability or admission of wrongdoing by Monogram.