Quote:
Originally Posted by spinner1001
That sums it up pretty concisely.
The public does not have TVH contracts to say how TVH finances actually work and many posts are mostly BS.
I subscribe to a specialized AI platform for deep research. I had it write a report on Medicare Advantage micro economics from CMS to MA plans to MA clinics. The document is long and dense for two reasons. The government's MA program is complicated and, second, for clinics, MA micro economics depend on their particular contracts with MA insurance plans. Contracts differ. If you have seen one contract, you have seen one contract.
Below is a link to the report on Medicare Advantage micro economics from CMS to clinics (providers). Again, it's long and dense. Happy reading. There will be a quiz next Friday.
Dropbox |
The article is long and dense!
The more I look at this issue, the more confused I get. I started out thinking that Medicare pays Medicare Advantage a certain amount of money each month for each patient.
This is from the Medicare handbook.
When you join a Medicare Advantage Plan, Medicare pays a fixed amount for your
coverage each month to the private company offering your Medicare Advantage Plan.
And this is from another website.
Rather than directly covering care as needed, the federal government pays lump sum Medicare dollars, known as capitated payments, to these private insurers for each patient.
I thought that once Medicare makes the monthly payment to UCH, Medicare is out of the picture and Medicare Advantage is responsible for making any payments to the doctors or clinics.
That is why I can't figure out how Medicare is involved. They made their monthly payment to UHC and UHC had to pay for medical treatment submitted by TVH. If TVH was making mistakes in coding, UHC would be the victim - not Medicare.
However, after reading the TVH bankruptcy filing, it appears that the major issue was that the HCC codes were incorrect and this lead to higher RAF scores which in turn lead to higher payments from Medicare to UHC. But I still can't see how TVH benefited from that. Wouldn't the payment go directly to UHC (or Humana or Blue Cross)?
The goal seems to be to get as much money from Medicare and spend as little money on medical treatment.
There was an article in the NY Times on October 8, 2022, discussing how the MA insurers were being sued for adding additional illnesses to their patients' records. However, it said nothing about how doctors or clinics were benefiting from the HCC codes and RAF scores.
Perhaps there is something in the contracts between TVH and the MA insurers that would explain this. Hopefully, it will come out in the bankruptcy proceeding or the Villages Daily Sun.