Monogram Health to pay $2.4M over four flagged HCCs; malnutrition and stable angina no longer map under V28

On August 24, 2026, the Justice Department announced that Monogram Health agreed to pay $2.4 million to resolve False Claims Act allegations that it caused unsupported diagnosis codes to be submitted to Medicare Advantage. Monogram, a Tennessee company that provides in-home care to Medicare beneficiaries, settled through two entities, Monogram Health Professional Services PC and Monogram Health Inc.

The dollar figure is small next to recent settlements. What earns a coder's attention is the four HCC categories the government named, because the current payment model has already stopped paying for two of the conditions inside them: protein-calorie malnutrition and stable angina.

What the government alleged

The government alleged that from January 1, 2021 through December 31, 2023, Monogram caused the submission of diagnosis codes within four Hierarchical Condition Categories that were "not clinically accurate, not supported by documentation in the beneficiary's medical records, and/or did not require or affect patient care, treatment or management." According to the government, Monogram was eligible to be paid more by the Medicare Advantage plans when the beneficiaries in its care carried higher risk scores, and those risk-sharing arrangements gave it a financial incentive to submit additional diagnosis codes.

Those are the government's contentions. The Justice Department states the claims resolved by the settlement are allegations only, and there has been no determination of liability. The case resolves a lawsuit filed under the False Claims Act's qui tam whistleblower provisions by Dr. Ajay Gupta, a physician formerly employed by Monogram, who will receive approximately $380,000 as his share of the recovery. The matter was handled by the U.S. Attorney's Office for the Central District of California.

The four HCCs at the center of the case

The government named four categories by their CMS-HCC V24 numbers, which is the model that was in effect for the 2021 to 2023 payment years the settlement covers:

• HCC 21, Protein-Calorie Malnutrition
• HCC 55, Substance Use Disorder
• HCC 48, Coagulation Defects and Other Specified Hematological Disorders
• HCC 88, Angina Pectoris

If you code today, none of those V24 numbers are your model anymore. V28 has been fully operative for payment since January 1, 2026, and it renumbered, split, and in several cases removed the categories a V24-era case turns on. One of the four here is gone from the model, and a second, angina, is gone except for its unstable form.

Where those four categories stand under V28 today

Here is how each category the government named maps under the current model. The settlement named the HCC categories, not specific codes, so representative codes are shown.

Malnutrition dropped out, and angina nearly did

Malnutrition is the clean removal. Under V24, codes like E43 (unspecified severe) and E44.0 (moderate) rolled into HCC 21 at a community weight of roughly 0.455. Under V28 the whole family, E40 through E46 plus cachexia (R64), maps to no HCC. Malnutrition still belongs in the record when the clinical criteria are met, but in 2026 it doesn't add to a risk score.

Angina nearly followed it. Stable and unspecified angina fell out of the payment model, and only unstable angina (I20.0), and coronary artery disease with unstable angina (I25.110), still map, to HCC 229 (Unstable Angina and Other Acute Ischemic Heart Disease) at a community weight of 0.240. The vague angina code an audit would once have chased for HCC 88 now adds nothing. For the full picture of what V28 kept and dropped, see the V28 model breakdown, and for a closer parallel, the sister case where a risk-sharing management company settled over the substance-use and mood-disorder categories, Complete Health's $14.1 million settlement.

The other two categories survived but narrowed. Substance use split by substance and severity, so the abuse-versus-dependence call is now a real payment distinction, not a formality. Coagulation defects split into a hemophilia category and a specified-defects category, and the unspecified coagulation code doesn't map at all. It's the same pattern V28 applied everywhere: specific, documented conditions still risk-adjust, and vague, unspecified ones don't.

Why a risk-sharing arrangement raises the stakes

The government's theory here is the same one behind several recent risk-adjustment cases. When a provider or management company is paid a share of what the plan collects from CMS, every diagnosis it adds that raises a risk score is also revenue to itself, and the government alleges that incentive is what drove the unsupported codes. The practical read for a coder working under a percentage-of-premium or shared-savings contract is that a coder-suggested addend carries more audit exposure, not less, because the money motive is written into the arrangement. Independent provider documentation is the thing that neutralizes it. This settlement lands the same week as The Villages Health's $541.5 million settlement, a reminder that the enforcement lane runs from a small in-home care provider to a large health system.

Where this lands on a coder's desk

So give the four families a focused review, but run them against the current model, not the V24 numbers in the settlement. One of them is gone from payment, a second maps only in its unstable form, and the last two pay only on the specific codes. In a three-year-old complaint, the category number is the least reliable thing to code from.