Introduction
Providers are adopting autonomous coding systems that submit claims with no human reviewer in between, yet every claim still carries the provider’s name, number, and full legal liability. A single misconfigured rule can replicate across thousands of encounters before anyone notices. This paper maps where the exposure begins, why automation multiplies rather than transfers risk, and what leaders must do before an algorithm bills in their name.
Key Takeaways
- 2026 False Claims Act penalties run $14,308 to $28,618 per claim, plus treble damages
- Penalties are assessed claim by claim, so one flawed rule becomes thousands of violations
- UCHealth paid $23 million over a single automatic emergency-visit coding rule
- CMS estimated $28.83 billion in improper Medicare payments for FY2025
- Over three-quarters of Medicaid improper payments stemmed from insufficient documentation, not fraud
- Audit logs must capture model version, inputs, and human reviewer for every claim