The Justice Department announced Oct. 6 that AIDS Healthcare Foundation, a Los Angeles nonprofit, agreed to pay $1.44 million to resolve False Claims Act allegations about Medicare Advantage billing. The government alleges it submitted, or failed to delete, false or invalid diagnosis codes that increased payments from the program.
The claims involve special needs Medicare Advantage plans run by the foundation's managed care division, operating as Positive Healthcare Partners, for beneficiaries with HIV in Florida, Georgia and California. The settlement covers payment years 2017 to 2023. The government says coders kept spreadsheets of inaccurate or undocumented codes but did not delete them in time. For 2017, it also alleges HIV diagnosis codes were submitted without documentation of a face-to-face visit, which CMS requires.
Medicare pays Advantage plans a fixed monthly amount per enrollee, adjusted for risk, so diagnosis codes affect how much a plan is paid. The Justice Department says the foundation received credit for cooperating, improving its compliance program and submitting deletes for unsupported codes during the investigation.
The case began with a whistleblower suit by a former coder, Donna Irons, who will receive a share of the recovery. The settlement resolves allegations only; the release does not describe it as a finding of liability, and it announces no change to enrollees' benefits. Anyone who suspects Medicare fraud can report it to HHS at 800-447-8477.