[JustSomeGuy]

Originally Posted by OrangeBlossomBaby

None needed. It was made transparent. TVH performed an audit (it wasn't the IRS forcing them to get audited, this wasn't a government investigational audit). They caught a really large flaw in their coding processes, that resulted in millions of dollars over a 4-year period being billed to insurance, that would've been less if they'd used the correct billing code. I'll lay it out again here since it's obviously been missed from my previous post somewhere on this forum:

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

The billing department receives the notation from the doctor's office that the patient had a checkup, AND that the patient came in with a lesion they needed to discuss.

The billing department mistakes this for two separate visits, and bills P1301 and P1462, for a total of $370. The patient pays nothing since both are still covered at 100%. TVH gets paid $370.

There's no fraud. Both of these things happened, no one is lying, no one is intending to steal money from anyone. But the people in the billing office probably had never seen these as the SAME VISIT before, and had always billed it out as separate codes, and never thought they'd need to check to find out if there was a different code for that. So they did this for EVERY patient who came into the office for a checkup, with a lesion they wanted to talk to the doctor about.

Just $170 overage, but multiply that by thousands of patients, and the billing department making the same miscode for four years in a row, and you're looking at millions of dollars in erroneous coding and erroneous payouts. The patient never sees a bill, because it's all covered. And when they look at their monthly explanation of benefits, they see exactly what they experienced: they went in for a checkup. They also discussed a lesion with the doctor.

The above example is hypothetical. Insert whatever made-up code you want, and insert any similar types of errors you want. Checkup + skin lesion is mine. Full physical with EKG for patients who are planning on getting surgery, versus full physical with EKG, plus new consultation for pre-surgery.

Any time there's a visit with a combination of "things the doctor does" there's a chance that there are a few different coding options. The doctor doesn't know billing codes. That's not his job. The billing office doesn't get to see the full notes of the doctor. It's none of their business. The doctor passes the notes to the office folks, who plug in what they believe the procedure numbers are, into the patient's billing file. The billing file gets forwarded to the billing office. The billing office determines the billing code to match the procedure codes, and the system spits out a bill.

Somewhere between the doctor's input and the bill to insurance, there were consistent errors. Likely something similar to the example I made above. Procedures that are fairly routine, that would be lumped together with one code if they happened on the same visit but have two separate codes, with two different fees charged, if they happen on different visits (even if those visits are consecutive, with one only 10 minutes after the other).

The habit of miscoding whatever the procedures were, happened as a convention, not as an intention to defraud anyone.

Every year they must create a budget. First year of over charges, no matter the reason, even if everything added up, someone would have seen that they exceeded their expected office visits by 100% and revenues by a similar amount using the above example. Big red flag missed... or ignored (likely). Next year they use those over inflated "codings" to set the budget.... and so on. Funds were used (Hmmm) for salaries and offices to handle the workload of the miss coded visits. If that were the case those seeking care would have seen almost half the appointment slots unused (if the villages healthcare did not know there was an error), doctors seeing half the expected appointments and half empty waiting rooms... every year since the first miscoding (which in the example double counted appointments, half bogus).

If they used the funds for other purposes, profit, overpaid the doctors and staff or overpaid on rent and did not expand staff and doctors then the funds disappear but patients notice no over staffing. The organization "knew" something was wrong since they were doing twice the business with the same staff.

If any other non-government business did this someone would be found at fault.

If they truly thought the billings were correct then those who will still be using the "new company" should see the staff (including Doctors) reduced significantly and offices downsized or closed since they inflated the workload and income by miscoding as noted in the example above.

Someone got the hundreds of millions they can't repay and which caused the bankruptcy. Time will tell who. If they do not cut the number of Doctors and staff, then it went somewhere else and that needs to be investigated.