AIDS Healthcare Foundation agreed to settle allegations involving unsupported Medicare diagnosis codes.
AIDS Healthcare Foundation has agreed to pay $1.44 million to resolve allegations that it submitted inaccurate or unsupported diagnosis codes to the federal Medicare Advantage program. The settlement was announced by the U.S. Department of Justice (DOJ) earlier this week and concerns claims associated with payments made in the six-year span between 2017 and 2023. The government stressed that the settlement resolves allegations only and does not represent a finding that AHF was legally responsible for wrongdoing.
AHF is a nonprofit organization that provides care and services to people living with HIV in the United States and other countries. Its Managed Care Division, known as Positive Healthcare Partners, operated Medicare Advantage special needs plans for people with HIV in California, Florida, and Georgia. The case centers on how Medicare Advantage plans report medical diagnoses. Under Medicare Part C, private health plans receive a set monthly payment for each person enrolled in their plans. The amount can change based on the person’s expected medical needs. Plans generally receive higher payments for patients expected to have more serious or costly health conditions.
Those payments are partly based on diagnosis codes reported by health care providers. The codes must be supported by information in a patient’s medical record and must be accurate and complete. A diagnosis that is more serious or expected to require more costly care can result in a higher risk score and a higher payment to the health plan.
According to the DOJ, AHF’s risk adjustment coders began reviewing patient records around 2017 to find diagnosis codes that were inaccurate or lacked support in the medical records. The coders kept spreadsheets known as “Delete Research” lists. These lists contained codes that appeared to need additional review before they could remain in the records used for Medicare payments.
The government alleged that AHF knew it had to investigate and remove inaccurate or unsupported codes within 60 days. Instead, most of the codes identified on those spreadsheets were not removed until 2024 or 2025. Those removals occurred after the organization had been notified about the federal investigation, according to the allegations. The government also alleged that AHF submitted HIV diagnosis codes for the 2017 payment year in cases where the diagnosis was not documented in a medical record from a required face-to-face visit. The alleged conduct formed part of the claims resolved through the settlement.
The case began after Donna Irons, a former AHF risk adjustment coder, filed a whistleblower lawsuit under the False Claims Act. That law allows certain private individuals to bring cases on behalf of the federal government when they believe public funds have been improperly claimed. A whistleblower can receive part of the money recovered by the government. Irons will receive $259,200 from the federal recovery under the settlement.
The Justice Department said AHF received credit for cooperation and steps taken to address the problems during the investigation. The organization worked with investigators, improved its compliance program, and submitted additional code removals after reviewing medical records and finding that certain diagnoses were not supported.
The government said accurate medical records and diagnosis codes are important because Medicare Advantage payments are based partly on the health needs of enrolled patients. False or unsupported information can result in payments that do not match the medical information available for a patient. Federal officials said keeping diagnosis information accurate helps protect taxpayer funds and supports the proper use of Medicare resources. The case also serves as a reminder that health plans are expected to review and correct information when problems are found.
Sources:
AIDS Healthcare Foundation Agrees to Pay $1.44M to Settle False Claims Act Allegations
LA.-based AIDS foundation to pay $1.4 million in False Claims Act settlement
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