Quote:
Originally Posted by Rainger99
This is the best explanation that I have seen for the coding discrepancies. It is from the TVH's bankruptcy filing.
TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that Centers for Medicare and Medicaid Services (CMS) pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.
I thought that the insurance companies receive larger payments - not the TVH.
Article on Risk Adjustment Factor (RAF) score fraud.
Understanding Risk Adjustment Factor (RAF) Score Fraud and How to Get a Reward for Reporting It - Daniel J. Ocasio Whistleblower Law Group |
Quote:
Originally Posted by OrangeBlossomBaby
You only pay your co-pay, which is probably 0 since it was all part of your physical exam.
But the insurance company sees the code for the podiatry consultation, and sends your doctor's office a check for $197 instead of $143, because an annual physical plus podiatry consultation pays out $197.
But here's the thing - there are 7 different billing codes that COULD be input, for a brief moment's worth of discussion with a doctor during an annual physical about your bunion. The one your doctor's billing department chose was the wrong one. The one they were supposed to choose should have resulted in a $146 payment, not a $197 payment (and not the bare-bones $143 payment either).
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I thought with Medicare Advantage Plans, the Payments from Medicare were essentially as Rainger laid out. A "monthly payment per patient", based on their level of need.
I thought traditional Medicare (NON Advantage Plans) made payments per what OBB laid out.
It can't be both ways. Either they pay a "lump sum" per month, based on a Patient's level of complication or they pay individually, for specific procedures.
It sounds to me, like two separate and distinct Medicare fraud/over-billing/mis-coding. In one instance, the patient's general health/complications are inflated for a larger monthly payment.
In the other instance, the patient's individual procedures are miscoded or exaggerated.
Which is it?