[golfing eagles]

Originally Posted by JustSomeGuy

I trust you have much more experience in this than the rest of us but just saying wrong, wrong, wrong is not proof you are right.

The bankruptcy filing says: An internal investigation, supported by Goodwin Procter and FTI Consulting, revealed that a retrospective chart review program initiated around 2020 was inconsistent with Medicare guidelines.

We agree they have a budget each year. When setting their budget after this change, say for 2021, they must have planned for almost twice the income per claim or they exceeded budget by a tremendous amount. They had been open since 2012 so they had a good history to forecast from. Those seeing the "New" budget knew they somehow were able to double their income per patient with no other action except a change in billing practice from the previous 8 years.

Also stated in the filing is the fact that: "The program resulted in the submission of unsupported Hierarchical Condition Category (HCC) codes, which improperly inflated patient Risk Adjustment Factor (RAF) scores and, consequently, the capitated payments TVH received from Medicare Advantage plans." So the observation made that I was responding to - "

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."

Does not match this situation where they actually took the same visit say for obesity and upgraded it to morbid obesity, increasing risk factor and increasing their payment. Or they up coded asthma to COPD. They were not changing one visit as noted above as two, which would not impact the risk score and is not listed in the bankruptcy filing documents.

As far as the last part of my statement you said was wrong. The developer owns 61% of Villages health, Villages health is an "asset light" organization. They lease everything (equipment and clinics) and own little. They have little debt, except the repayment of 320 million. Their main asset is their workforce. (from the bankruptcy files themselves, available on line) In 13 weeks the bankruptcy budget shows they loss 5,000,000 plus with two months rent (1,100,000 each) not included for some reason. This loss was evidently covered by the excess billing that is no longer happening. How will the new company continue to fund the same staff with the loss of 64,000 million in revenue per year (320 million divided by 5)?

Those are the issues you do not address. Someone deliberately started a new billing process (which caused CenterWell to immediately pull out of a non binding agreement to buy last summer when they saw it) in 2020. Was this billing change intentionally improper? CenterWell knew it was improper. How is the new buyer after the bankruptcy, going to continue to employ the same people if the only asset they have is the workforce and if they need to cut costs by $64,000,000 per year (no one has the money hidden anywhere, correct?)? They can't sell assets and lease them back to reduce costs.

FYI, the developer will get 60% of the 39 Million if the sale and the bankruptcy goes through. Taxpayers lose 320,000,000. Patients will see cuts in employees. If not, then the $320,000,000 was not used to cover day to day business costs. It was a was taken out of the business. CenterWell is not going to lose 64 million a year. If they do not need to cut costs then the 320 million was take as profit or some other non-recurring payment that can just end when the improper billing ends.

You are assuming that coding/billing somehow "changed" in 2020. The statement is ONLY that a retrospective review started looking at billing from 2020 to the present, it does not address 2012-2020. If the same billing and coding practices were in place from 2012 to 2020, your whole premise falls apart. NO adjustment in budget. No doubling the revenue. Just business as usual.

Now here's a concept I haven't considered: Many posters are considering the $361 M as "extra" and want to know where the money went. What if (hypothetical) they only broke even and without the "overpayments" they would have been in $361M of debt, ie: bankrupt a long time ago?????