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Originally Posted by spinner1001
This means CMS’s MA payment to the insurance company is higher for sicker beneficiaries and lower for healthier beneficiaries. See the first link in my previous message. One aspect of this is a medical provider might upcode their services to make patients appear sicker so the CMS payment from the government is higher.
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So is that what happened here? The Medicare Advantage insurance companies were not over billed but Medicare overpaid on the capitation rate because TVH upcoded to make patients appear sicker than they actually were.
Even if you increased the capitation from $1,000 to $3,000, that would be $2,000 overpayment per patient so it would have to 45,000 patients to over bill $90,000,000.