Quote:
Originally Posted by tophcfa
- The Villages Health (TVH) ran a unique business model for a large health care provider serving predominately a senior community. Unlike just about ever other similar health care provider, TVH primary care operation has not accept traditional medicare, only specific Medicare Advantage plans.
- Upcoding, when more diagnoses than are actually present are reported to increase medicare payments, are very rare with traditional Medicare and are almost exclusively limited to home care. On the other hand, upcoding has been widely abused with Medicare Advantage plans because under MA plans, payments are made on a risk-adjusted basis meaning higher risk scores (based on reported diagnoses) lead to higher payments.
- Despite the fact that patients with traditional Medicare and supplemental plans are generally sicker and require more health care than Medicare Advantage plan holders, Medicare Advantage plans pay out, on average, 22% more per patient than those with traditional Medicare.
- Without audited financial statements, including a detailed sources and uses of funds statement, it is impossible to figure out what happened to the $$$ referenced by the author of this thread. That being said, based on the bankruptcy filing information, the amount of reported assets relative to liabilities certainly indicates the money wasn't retained in THV surplus account.
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The above Upcoding explanation is lacking. For a more complete understanding
UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING? - PMC
I don't know where this information came from as far as sicker population, but it doesn't match my 40 years' experience. Generally, government Medicare vs MA plans are chosen based on preferences, e.g. I have MA because it covers dental, vision, hearing, gym, etc. and government Medicare doesn't. Medicare doesn't have "network providers", you go where you chose that takes Medicare, whereas MA plans have a network and the plan you chose determines how broad the network (mine covers all my doctors here and all my doctors up north.) As for Medicare vs MA payments "The plans must follow rules and standards set by Medicare. The federal government pays Medicare Advantage plans to provide all Medicare-covered benefits. If there is a difference between the amount a Medicare Advantage plan is paid by Medicare and the plan’s actual cost to provide benefits, the plan must use any savings to provide additional benefits or reduce costs for members of the plan. This is how some Medicare Advantage plans provide coverage for services such as routine vision care and routine dental care, which are not covered by Medicare."
As for where the money went; Pre-COVID, our hospital operated very lean and ran in the back. Post-COVID, our hospital was grossing more than it had ever grossed and was losing $2M/month mostly because of staffing costs, since many left the medical field and were replaced by travelers at nearly 3x cost. I wouldn't assume the money did more than plug holes in a sinking ship.... but I could clearly be wrong and time will tell.