Quote:
Originally Posted by BrianL99
Based on the fact that Medicare is saying TVH "over-billed" them, that must mean that Medicare pays TVH directly (which surprises me). It sounds like the Insurance carrier is just a "middle man", providing management of the patient/doctor relationship.
With 100's of posts on the subject, it seems someone must actually know the formula for how TVH gets it's revenue and from whom. Again, Rainger & OBB's characterizations of the payment structure/arrangement are diametrically opposed ... two separate and distinct arrangements.
Does Medicare pay TVH a specific amount per patient, regardless of what or how many procedures they have (adjusted only for bonuses and/or "complexity" level of their conditions) ....
Or ... does Medicare pay TVH per visit and/or per procedure, as OBB claimed in the bunion story.
& how does the insurance company get paid, if they're not billing Medicare directly?
Call me crazy, but if no one understands how billing and payments actually work, how does anyone have an opinion on who's getting pork'd and how?
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From some very quick reading, here is one possibility:
- A Medicare Advantage (MA) plan receives a monthly amount ($1,000?) per patient regardless of any treatment
- The monthly amount is intended to be more than enough to cover costs which allows the MA plan to off additional services
- The provider sees patients and bills the MA plan for services provided
- If the services provided indicate the patient is sicker than average then the MA plan can bill Medicare extra for that patient
- The additional money paid by Medicare is passed through MA to the provider
- TVH may interact only with the MA plan
- TVH requests reimbursement through coding
- If the coding is within a "normal" range of services, the MA plan reimburses TVH from the monthly amount it receives for that patient
- If the coding is above normal (sicker patient) then MA requests additional funding from Medicare
- The additional funding is passed to the TVH
If it is later found that the "above-normal" coding was inaccurate then Medicare may choose to demand reimbursement. Since the coding was done by TVH and the additional funds were given to TVH it is logical that Medicare would approach TVH for any reimbursement.
Since TVH doesn't have $360M just sitting around to be used for reimbursement, it anticipates a serious problem and has filed for bankruptcy protection.
The above is certainly missing some details and nuances but it seems to be consistent with the description of the flow of funds with Advantage plans and what has been reported in various articles.