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Old 07-16-2025, 09:54 AM
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Originally Posted by Topspinmo View Post
Don’t doctors practices hire people to do paperwork/coding and insurance? And if work for company on salary contract don’t company hire people to do insurance/coding collecting? If not then it’s either the doctor or company mis-coding. Plenty examples especially in Florida over year’s of practice’s and doctors being prosecuted for Medicare fraud far less money, why should this practice be any different. Intentionally or not still millions dollars and want get out of paying it back by filing bankruptcy?
There are various methods for coding. The first is "point of service"--the provider codes the visit at the same time he generates the progress note. The drawback is that the provider needs to be familiar with CPT coding. TVH does not use that method, primarily because they are not paid by CPT code. Medicare Advantage plans capitate payments by diagnostic complexity and number of patients, which is quite different from traditional Medicare.

Another method if you are large enough is to have professional coders that work for you and evaluate the documentation and assign a CPT code---again, not relevant to Advantage plans.

Many medium size practices simply outsource billing and coding to a third party, usually for about 8% of the billing.

The mess TVH finds itself in is not CPT coding (although that would apply to the specialty clinics), but with the use or misuse of ICDM-10 codes, which have a lot of ambiguity and room for interpretation. Now, were the providers stretching the limitations of the coding definitions? Maybe, but I doubt that since as salaried employees they have nothing to gain. At some higher level was the coding tweaked or even falsified? I doubt it but anything is possible. Most like they simply used an aggressive coding philosophy that CMS decided was wrong. And they don't "get out of it" by declaring bankruptcy, they declare bankruptcy because they can't pay it back.