I don’t understand how the government is involved. If the Villages was mistakenly over billing by $90 million a year, wouldn’t they be over billing the Medicare Advantage plans - UHC, Humana, and BCBS?
From my research, Medicare pays a fixed amount each month to the private insurance company offering the plan to cover your medical expenses.
Medicare pays the insurance company a predetermined, fixed monthly amount (often referred to as a "capitation payment") for each enrollee, regardless of the actual medical services used. Apparently this is about $1,000 a month!!!
The insurance company, not Medicare, is responsible for managing and paying for your healthcare services. When you receive medical care, the provider (e.g., doctor, hospital) bills the insurance company administering your Medicare Advantage Plan, not Medicare directly.
In Original Medicare (Parts A and B), providers bill Medicare directly for covered services, and Medicare pays its share (typically 80% for Part B services), with you covering the rest (e.g., 20% coinsurance).
In contrast, Medicare Advantage shifts the financial risk to the private insurance company, which receives the fixed payment and manages all claims.
So if the insurance companies were over billed, how is Medicare involved?
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