June 3, 2026. After receiving a False Claims Act qui tam complaint from the Whistleblower, the United States Department of Justice investigated and resolved the lawsuit against Community Care Health Network, LLC d/b/a Matrix Medical Network. A copy of the Whistleblower (Relator) Team’s complaint is here. A copy of the Department of Justice, Matrix, and Relator settlement agreement is here. The Government’s Complaint in Intervention is here. A link to the Department of Justice press release is here.
The settlement resolved allegations that that Matrix violated the False Claim Act by causing the MAOs to submit false and invalid patient diagnoses for certain chronic conditions, thereby artificially inflating the Medicare payments the MAOs received for providing insurance coverage to patients enrolled in their plans; and that Matrix focused on reporting diagnoses that could lead to higher payments for its client MAOs, instead of ensuring that all of its diagnoses were appropriate and well-supported.
As part of this settlement among the United States, Matrix, and Relator, Matrix admitted and accepted responsibility for certain conduct alleged.
- It contracted with over 30 MAOs to conduct health assessments of Medicare Part C plan members in their homes.
- The in-home assessments were typically performed by nurse practitioners, who collected health histories and medication information, conducted physical exams, and documented diagnostic information on electronic health assessment forms. The nurse practitioners did not provide clinical medical treatment to the plan members or prescribe medications.
- Certain contracts with MAOs required Matrix to, among other things, assist the MAO in “capturing Member diagnoses for use in [MAO’s] risk adjustment process” and report on the MAO’s “ROI,” or return on investment. Matrix calculated an MAO’s ROI based, in part, on the estimated increase in Medicare Part C reimbursements received by the MAO that was attributable to risk score increases resulting from Matrix assessments.
- Its in-home assessments resulted in diagnoses of plan members, and the submission to CMS of resulting risk-adjusting diagnosis codes, that frequently had not been reported by any other healthcare provider who treated the plan member during the year in which the home visit occurred or during the two years before and after the calendar year in which the home visit occurred.
- In numerous instances, it reported the following conditions to MAOs where the health assessment forms did not contain sufficient clinical information to support the diagnosis: proliferative diabetic retinopathy; drug-induced polyneuropathy; rheumatoid polyneuropathy; atrial fibrillation; rheumatoid arthritis; chronic obstructive pulmonary disease; and simple chronic bronchitis. The MAOs in turn frequently submitted the diagnosis codes corresponding to those conditions to CMS for risk adjustment purposes, which often resulted in the MAOs receiving higher Medicare Part C reimbursements.
Healthcare kickbacks are harmful to patients because they corrupt independent medical decision-making and prioritize financial gain over patient health and safety. When medical choices are driven by money, the integrity of the entire healthcare system is seriously compromised and patients mistrust healthcare providers.
The Relator’s Complaint also led to the imposition of a Corporate Integrity Agreement (CIA) required by HHS-OIG. A copy of the requirements under the CIA is here.
The whistleblower, also known as a qui tam relator, was a former employee of Matrix. The case highlighted the critical role that employees play in disclosing their concerns of potential kickbacks among healthcare organizations to the U.S. Department of Justice. “The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable.”
Civil prosecutors for the U.S. Attorney’s Office for the Southern District of New York are responsible for this important resolution. Whistleblower attorneys Renée Brooker and Eva Gunasekera represented the qui tam relator. Contact them at reneebrooker@tzlegal.com and eva@tzlegal.com. This settlement exemplifies the success of the False Claims Act public-private partnership between the U.S. Department of Justice and Whistleblowers to hold the healthcare industry accountable for actions that impact government programs (Medicare—both traditional and Medicare Advantage—Medicaid, TRICARE, VA Health, and FEHB) funded by U.S. taxpayers.