Kenia Valle Boza, a certified coder who worked at Pasteur Medical Center and later HealthSun Health Plans, allegedly participated in a scheme to fraudulently increase Medicare payments by:
- Falsely diagnosing beneficiaries with risk-adjusting conditions.
- Having coders enter false diagnoses directly into medical records.
- Using physicians’ login credentials to make it appear doctors had diagnosed conditions.
- Specifically targeting conditions like ‘Other Hemoglobinopathies’ and ‘Disorder of Carbohydrate Metabolism, Unspecified’ based on elevated HbA1c test results, which was not a proper diagnostic basis.
The indictment was brought in October 2023, and after a two-week jury trial, Ms. Valle Boza was found not guilty on all charges on June 16, 2025.
HealthSun was not criminally charged, and the Department of Justice declined to prosecute the company. This case highlights the growing risk of certified coders. This raises the question of whether there will be more cases similar to this as the Centers for Medicare and Medicaid Services increase their auditing efforts on Medicare Advantage risk adjustments. Perhaps, this case opens the door to other criminal cases against coders and billers who enter charges and codes as documented by physicians.
