Significance Of Recent DOJ Managed Care Settlement

The Department of Justice’s $14.1 million settlement with Complete Health Partners Holdings in August 2026 is a reminder that Medicare Advantage risk adjustment remains a high-priority enforcement area. The government’s case centered on allegations that unsupported diagnosis codes increased risk scores and, in turn, Medicare Advantage payments. For managed care organizations, the settlement underscores that coding accuracy is not simply a provider documentation issue; it is an enterprise compliance obligation that extends across clinical documentation, provider prompts, coding guidance, chart reviews, vendor oversight, delegated arrangements, and final submissions. The settlement also highlights the compliance risk created by incentives that reward higher risk scores without equally strong controls to confirm clinical validity.

Organizations should evaluate whether coding tools, chart review processes, and physician queries are designed to support accurate documentation—or whether they could be interpreted as encouraging diagnoses that are not supported by the medical record or connected to patient care. The central lesson of this enforcement action is that Medicare Advantage payments must be grounded in diagnoses that are clinically valid, well documented, and relevant to the beneficiary’s care. Compliance officers should treat this settlement as a prompt to revisit risk adjustment governance. The practical message is that oversight should be proactive, documented, and independent enough to identify unsupported codes before they are submitted.

Tips for Compliance Officers

1. Ensure coding policies and procedures are up to date and consistently applied.
2. Conduct targeted testing of high-risk Hierarchical Condition Categories.
3. Audit physician query practices to confirm that they support accurate documentation.
4. Strengthen oversight of vendors and delegated entities.
5. Ensure corrective action is taken promptly when unsupported codes are identified.

Interested in learning how Strategic Management can support your compliance team and program? Contact Richard Kusserow at [email protected].

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.