BC Advantage - 2026 Issue 3

Diagnosing Danger: AI-Generated Diagnosis in Medicare Advantage Coding

An enforcement area for the United States Government is adding diagnoses that allegedly fraudulently increase Medicare Advantage (MA) plan payments. For example, in July 2023, Martin’s Point Health Care, Inc. resolved False Claims Act (FCA) allegations and agreed to pay $22,485,00 (Justice, U. S. [July 30, 2023], Martin’s Point Health Care Inc. to Pay $22,485,000 to Resolve False Claims Act Allegations).   Although the Martin’s Point case did not involve generative artificial intelligence (AI), the practice of skewing codes to increase a risk adjustment score may be increasing due to AI programs...

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