Jacksonville, Florida, August 3, 2026— Complete Health Partners Holdings LLC, a management services organization that operates primary care practices in Florida, Alabama, and Colorado, has agreed to pay $14.1 million to the federal government to settle allegations that it submitted inaccurate risk adjustment data in order to increase Medicare’s payments for its patients. The settlement resolves a whistleblower lawsuit that Phillips & Cohen LLP filed in 2022.
The allegations in the lawsuit concern the Medicare Advantage program, under which Medicare beneficiaries may choose to enroll in private health plans instead of traditional Medicare. In traditional Medicare, the government covers healthcare costs by paying providers for their services. Under Medicare Advantage, the government instead pays the insurance premiums charged by the Medicare Advantage plan for enrolled beneficiaries.
The amount the government pays for each beneficiary in a Medicare Advantage plan is “risk adjusted” based on their health status and demographic information. Medicare Advantage plans report their members’ health status to Medicare using the diagnoses their members receive from healthcare providers. Reporting a diagnosis to Medicare can increase the plan’s reimbursement by thousands of dollars a year.
The lawsuit alleged that Complete Health providers diagnosed patients with conditions the patients did not have or for which there was insufficient evidence, so that Medicare Advantage plans that contracted with Complete Health could claim millions of dollars in additional payments from Medicare. Complete Health allegedly stood to benefit from the false diagnoses because Medicare Advantage plans paid it a share of the additional money they received, an arrangement known as “risk sharing” or “sub-capitation.”
The settlement resolved claims with respect to two conditions, drug and alcohol dependence and major depressive disorder, which Complete Health allegedly pressured providers to diagnose when those conditions were not clinically valid, were unsupported by medical records, or were unconnected to the care the patient received.
“The decision to diagnose a patient with a medical condition should never be influenced by the provider’s own financial interests,” said Edward Arens, a partner and whistleblower attorney with Phillips & Cohen LLP. “This settlement reinforces that diagnoses should be based on medicine, not money.”
“We alleged that Complete Health’s improper diagnoses cost Medicare millions of dollars,” said Arens. “The government has made risk adjustment fraud a top priority and demonstrated that commitment by taking swift action to investigate our client’s allegations.”
The lawsuit was brought under the False Claims Act, which allows whistleblowers to receive up to 30 percent of money collected for fraud against the government. The Department of Justice investigated and intervened in the lawsuit. Phillips & Cohen thanked Trial Attorneys Olga Yevtukhova and Jennifer Koh and Assistant U.S. Attorney Sean Keefe for their work on the case.
Phillips & Cohen is the nation’s most successful law firm representing whistleblowers. The firm’s cases have helped recover more than $13 billion in civil settlements and criminal fines. Phillips & Cohen represents whistleblowers in qui tam lawsuits as well as whistleblower claims under other reward programs, including the SEC, CFTC, and IRS whistleblower programs. If you are aware of potential fraud involving government programs or funds, contact Phillips & Cohen to discuss your situation confidentially.
DOJ Press release: https://www.justice.gov/opa/pr/medicare-advantage-provider-complete-health-pay-14100000-settle-false-claims-act-suit