On August 4, 2026, the United States Department of Justice (“DOJ”) on behalf of the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services announced it had entered into a $14.1M settlement with Complete Health Partners Holdings (“Complete Health”), a Florida management services organization (“MSO”), to resolve allegations that Complete Health submitted false risk adjustment scores in violation of the False Claims Act. As an MSO, Complete Health provides non-clinical administrative and operational support to medical practices and health care providers, including payer contracting. Complete Health entered into risk-sharing agreements with Medicare Advantage Organizations (“MAOs”) under which it received a percentage of payments made to the MAOs and, as a result, allegedly had a financial incentive to increase the scores. The matter stemmed from a qui tam suit initiated by a former risk adjustment employee for one of the MAOs with which Complete Health contracted on behalf of its managed provider groups.
Between 2020 and 2023, Complete Health allegedly submitted clinically invalid diagnosis codes to increase the risk adjustment scores of patients in its managed groups by targeting two Hierarchical Condition Categories (“HCCs”): HCC 55 (Drug and Alcohol Dependence) and HCC 59 (Major Depressive, Bipolar and Paranoid Disorders). The DOJ alleged that Complete Health presented incorrect coding guidance to its coders and physicians regarding diagnosis codes encompassed in the target HCCs and prompted physicians to include the diagnoses in patients’ medical records even if the diagnoses were not clinically justified or substantiated. In addition, coders allegedly would add diagnosis codes to patients’ medical records without the physicians’ knowledge or consent.
CMS’s Focus on Risk Adjustment Continues to Expand
Medicare risk adjustment has been a focus of the Centers for Medicare & Medicaid Services (“CMS”) for several years. In January 2026, CMS implemented a new risk scoring system for MAOs, known as the v.28 HCC Risk Adjustment Model. This model uses a patient’s age and documented health diagnoses to determine MAO payment, emphasizing the severity of the patient’s conditions rather than the total number of diagnoses listed in the medical record.
CMS reviews MAO risk-adjustment submissions through Risk Adjustment Data Validation (“RADV”) audits to confirm that the submitted risk scores are supported by the patient’s medical record. Due in part to delays caused by the COVID-19 pandemic, CMS fell behind on RADV audits. However, CMS has released a schedule to complete RADV audits for benefit years 2019 through 2025 by the end of 2026 and has indicated its intent to remain current going forward.
Staying current compresses the timelines for both providers and payers to complete their risk adjustment roles. As payers will have shortened timeframes in which to audit medical records and suggest additional diagnoses, providers and coders will be challenged to ensure diagnosis codes are accurately charted and capture the patient’s full clinical picture at the time of treatment.
Compliance Program Implementation Is Essential
The Settlement Agreement illustrates to health care entities the importance of an effective compliance program, highlighting the OIG’s recently updated guidance in the General Compliance Program Guidance, newly released Medicare Advantage Industry Segment-Specific Compliance Program Guidance and updated Corporate Integrity Agreement. These updates expand on the CMS-mandated seven elements of an effective compliance program, moving beyond form and policy and requiring health care entities to document their processes, outcomes and mitigation of noncompliant elements. The expanded requirements provide the health care entity, its management and its board with additional metrics and compliance-focused discussion to better govern the entity. The OIG also introduced an annual assessment by a third-party compliance expert to assist in identifying potential risks that may result in noncompliance. Leadership and the compliance officer can use the assessment report to focus resources on strengthening controls, thereby correcting potential noncompliance.
Practical Takeaways
- Consider potential RADV exposure through data analysis and auditing medical records.
- Use predictive analytics and algorithms to scan claims and medical records.
- Employ clinical teams to review audit findings.
- Involve in-house or outside legal resources for privileged legal analysis and guidance.
- Implement checks and balances to prevent single points of failure.
- Develop a checklist that captures the chart review process and requires completion by each involved team/individual.
- Use training and education teams to develop coder and provider training to educate on required charting elements to support diagnosis code(s) and/or HCC.
- Involve legal and/or compliance as needed to interpret submission guidelines and coding guidance.
- Consider hiring coding and data experts to complete data-mining and coding recommendations.
- Assess your organization’s compliance program and compliance with the newly released Medicare Advantage Industry Segment-Specific Compliance Program Guidance.
For more information or assistance in evaluating your risk adjustment program, please contact:
- Katherine Kuchan at kkuchan@hallrender.com or (414) 721-0479;
- Brandon Helms at bhelms@hallrender.com or (248) 457-7847;
- Jennifer Hatchett at jhatchett@hallrender.com or (859) 361-5706; or
- Your primary Hall Render contact.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.
