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Originally Posted by OrangeBlossomBaby
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.
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You say that the issue has to do with billing codes - not RAF or PMPMs.
This is from the Villages Health bankruptcy filing. They are claiming that.
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.
They are ones talking about PMPMs and RAF scores. In fact, I never heard of either term before yesterday.
Are you saying that the Villages Health lawyers are mistaken? That it wasn't about PMPMs or RAF scores?