AIDS Healthcare Foundation Agrees to Pay $1.44 Million to Resolve False Claims Act Allegations Over Medicare Advantage Diagnosis Codes

AIDS Healthcare Foundation, a Los Angeles-based nonprofit that provides care to HIV patients, has agreed to pay $1.44 million to resolve allegations that it violated the False Claims Act by submitting—or failing to delete—false and invalid diagnosis codes in order to increase payments from the Medicare Advantage program.

AHF’s Managed Care Division, doing business as Positive Healthcare Partners, operated special needs Medicare Advantage plans for beneficiaries with HIV in Florida, Georgia, and California. Under Medicare Advantage, the government pays plans a monthly amount adjusted by a risk score built from diagnosis codes, which must be accurate and supported by the patient’s medical record. According to the government, AHF’s risk adjustment coders maintained “Delete Research” spreadsheets listing diagnosis codes that appeared to lack documentation, but the organization failed to investigate and delete them within the required 60 days. Most of those codes were not removed until 2024 or 2025—well after AHF knew they may be unsupported, and only after the government notified it of an investigation. The United States also alleged that for payment year 2017, AHF knowingly submitted HIV diagnosis codes that were not documented in any medical record for a face-to-face visit.

The settlement resolves a qui tam whistleblower lawsuit filed by Donna Irons, a former risk adjustment coder at AHF, who will receive $259,200 as her share of the federal recovery. AHF received credit for its disclosure, cooperation, and remediation, including proactively deleting unsupported codes during the investigation. The claims are allegations only, and there has been no determination of liability.