AIDS Healthcare Foundation paid $1.44M over Medicare Advantage diagnosis codes

AIDS Healthcare Foundation, a Los Angeles nonprofit providing care to HIV patients, operated special needs Medicare Advantage plans as Positive Healthcare Partners for beneficiaries with HIV in Florida, Georgia and California. On October 6, 2026, the Justice Department announced AHF would pay $1.44 million to resolve False Claims Act allegations around the diagnosis codes it submitted to CMS for risk-adjusted Medicare Advantage payments.

Medicare Advantage pays plans a monthly, risk-adjusted amount per beneficiary: the sicker the documented diagnoses, the higher the payment, calculated through the HCC model. The government alleged that for payment years 2017 to 2023, AHF failed to timely investigate and delete diagnosis codes that were inaccurate or unsupported by medical records.

AHF's own risk-adjustment coders tracked suspect codes in 'Delete Research' spreadsheets, and although the rules required investigation and deletion within 60 days, most flagged codes were not deleted until 2024 or 2025 — after AHF was on notice the codes potentially lacked support, and only after being notified of the United States' investigation.

The United States also alleged that for payment year 2017, AHF knowingly submitted HIV (ICD-10 B20) diagnosis codes that no medical record documented as arising from a face-to-face visit, violating CMS requirements. The case began as a qui tam action by Donna Irons, a former AHF risk adjustment coder (United States ex rel. Irons v. AIDS Healthcare Foundation d/b/a Positive Healthcare Partners, No. 23-cv-2160, C.D. Cal.).

$1.44 million False Claims Act settlement; relator Donna Irons received $259,200 of the federal recovery

AHF's coders flagged unsupported diagnosis codes in 'Delete Research' spreadsheets, then most sat un-deleted for years past the 60-day deadline.

The flagged codes were only deleted in 2024 or 2025, after AHF knew they potentially lacked support and had been notified of the federal investigation.

For payment year 2017, AHF submitted HIV (ICD-10 B20) codes that no face-to-face visit record documented — the kind of code that raises risk-adjusted payments.

Risk adjustment pays more for sicker patients on paper, so every un-deleted or undocumented code inflated the monthly CMS payment.

A compliance queue you track but never clear is not compliance: knowing a code is suspect and leaving it billing for years converts a paperwork lag into fraud liability.

AHF agreed to pay $1.44 million to resolve the allegations. Under the qui tam provisions, relator Donna Irons receives $259,200 as her share of the federal recovery. Justice Department officials framed the settlement as a warning that Medicare Advantage organizations must ensure the accuracy of the diagnosis codes they submit — and that failing to correct information they know is wrong undermines a program millions of seniors rely on.