Quote:
Originally Posted by Rainger99
I am still confused. I thought Medicare Advantage worked the following way:
For every patient enrolled in UHC, Medicare pays a certain amount to UHC. This is based on your RAF rating (Risk Adjustment Factor). RAF is based on your overall health.
The average score is 1.00 and assuming that the average payment is $1000, UHC would get $1000 a month for each patient with an RAF rating of 1. If a person has a score of .8, UHC would get $800 a month and if a person had an RAF score of 1.5, UHC would get $1500 a month.
I thought that if UHC provides less care than the amount that Medicare pays each month that UHC keeps that as profit. And if UHC provides more care than the amount that Medicare pays each month, UHC has to make up the difference.
This is from the bankruptcy filing.
TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that 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.
In approximately August 2024, TVH became aware of a potential issue with respect
to its HCC guidance. At that time, TVH learned that it may have submitted HCC diagnosis codes that were not clinically supported or otherwise did not meet Medicare coding and payment guidance. For example, TVH engaged in a retrospective review program (in which patients’ medical histories were reviewed to identify instances in which TVH believed additional codes were supportable and could be added) that may not have been consistent with Medicare coding and payment guidance.
I think it means (but I am not sure) that if TVH assigned you a higher RAF rating, that TVH would get more per procedure so that TVH would have an incentive to assign people higher RAF scores. Do they get more procedure or do they usually have more procedures because they are in worse health?
I am not sure how this works with UHC. It seems that UHC would get more money each month also since their payment is based on RAF scores. If that is the case, does UHC owe Medicare a lot of money?
Is there someone that can explain this? A lawyer, a coder, a doctor?
Has anyone obtained their RAF score? I contacted UHC and they told me to contact TVH.
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That
Is
Not
What
Is
Happening.
I don't know how people can explain this to make it any more clear than has already been explained.
The "issue" with this incident of overpayment has to do with billing codes. Not RAF or PMPMs or guaranteed minimum monthly payments to the Health Center. It is specifically a billing code error.
Start there, and work your way back.