Quote:
Originally Posted by golfing eagles
Actually, you are more correct than you might think. TVH is paid on a diagnostic complexity per patient per month basis, different from straight Medicare.
|
Quote:
Originally Posted by golfing eagles
A patient taking aspirin after previous vascular surgery for say carotid occlusion has easy bruising. It gets coded as "acquired platelet dysfunction", which is exactly what it is. Or is it? Depends on interpretation. So the outside auditors for TVH tell them it is absolutely correct to use that code (Yes, they have continuous outside auditing). Then they get into negotiations with Humana, and Humana says that's wrong, you can't use that code in this instance.
|
If there's $360M in over billing, it seems the hammer needs to come down on someone, but it's not clear from your characterization, whether it should be TVH or Humana (I thought TVH was affiliated with United Healthcare?).
So either the local office (TVH) "coded" too low on the complexity scale and their Insurance company made them raise the "complexity score" (which would seem to indicate shared responsibility for the errors) or ...
The local office coded too high and the Insurance company insisted they lower the "complexity score". (which would mean they weren't getting paid (or billing) enough money, therefore no "fraud"?)
I'm sure I'm missing something in this equation, but I'm not sure what it is.