I’m a bit late to this thread because it literally took weeks for the administrator to approve my account. I’m not new to the Villages, but new to TOTV. I’ve been following along. I’m a semi-retired doc who, in my current role did a LOT of work to help prevent Medicare fraud in my organization, mostly about ensuring that we were compliant with legitimately reporting conditions for MA patients.
Since I am new on TOTV, the moderators won’t let me post links to some interesting articles But I will tell you what to google.
I’ve read the bankruptcy filings like everyone else and haven’t noticed many people focusing on the Risk Scores as the area of concern. While I don’t have inside knowledge of TVH inside workings, I understand how “overbilling” can happen with the risk scores and want to provide my perspective.
As a reminder, traditional medicare doesn’t use risk scores. But for MA, if a patient is more complex, then TVH gets more money to care for them in the outpatient setting.
Nearly EVERY MAJOR insurer has been caught with their hand in the cookie jar with “overbilling” (fraud) with adding unsupported risk scores. Don’t believe me? Then google “which insurers have been caught for fraud with medicare advantage risk scores”. One of the biggest offenders is United Health. The difference for TVH is that they can’t pay the fines and so had to file for bankruptcy.
Google another: OIG report finds insurers collected billions in questionable MA payments.
I also did not notice anyone mentioning that Florida Blue also filed a claim yesterday in TVH bankruptcy filing accusing TVH of adding unsupported diagnoses (also know as inflating risk scores). Google: Florida blue accuses villages health of adding false codes.
I’m not implying that TVH did this, only that other insurers did. But this article from WSJ outlines how United Health and other insurers hired ARNP’s to do home visits and pressured them to add “questionably” supported diagnoses (inflating risk scores). Each ARNP visit was estimated to inflate yearly payments by $2500-ish per patient. Google: The one hour nurse visits that let insurers collect $15B from medicare
Last, I’m calling out the apparent absence of oversight in TVH billing practices. Computer error or not, there should have been a corporate compliance officer who oversaw billing. Even if it was an innocent error, the compliance officer is accountable for this.
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