Villages Health DOJ investigation

[Kahuna32162]

Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health. I first thought it was a scam, but after hearing the personal information they had on our records, I was inclined to cooperate with their inquires.

They mostly wanted to confirm conditions listed in our files and confirm they were correct. Most conditions were not correct, especially type 2 diabetes.

I’ve thought for years that the Village’s Health was a scam. This active investigation might just be the tip of the iceberg.

[Mrprez]

???

[OrangeBlossomBaby]

Pretty sure you just got scammed by people taking advantage of billing errors and pretending to be members of the Dept. of Justice.

[vintageogauge]

Pretty sure you just got scammed by people taking advantage of billing errors and pretending to be members of the Dept. of Justice.
And exactly how did they get scammed and what did they get scammed out of? They didn't say they gave them information, they already had their medical records so they would have had to scam someone else that had the records.

[CarlR33]

Pretty sure you just got scammed by people taking advantage of billing errors and pretending to be members of the Dept. of Justice. I would agree…..from a simple web search below. While they only corrected information it maybe a test and the next call will be more in depth since they know you can be trusted over the phone. Also, you had to correct information they claimed they had so more than likely a phishing exercise setting you up for the next call that could be more a scam.

“If you receive a phone call claiming to be from the Department of Justice, be very cautious as it is likely a scam; legitimate government agencies, including the Department of Justice, will rarely contact you by phone to ask for personal information or money.”

[Bill14564]

I would agree…..from a simple web search:

“If you receive a phone call claiming to be from the Department of Justice, be very cautious as it is likely a scam; legitimate government agencies, including the Department of Justice, will rarely contact you by phone to ask for personal information or money.”

And if they only listened to personal information rather than providing it?


I agree that it sounds shady and I’m not sure how much I would say of if I was called.

[melpetezrinski]

Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health. I first thought it was a scam, but after hearing the personal information they had on our records, I was inclined to cooperate with their inquires.

They mostly wanted to confirm conditions listed in our files and confirm they were correct. Most conditions were not correct, especially type 2 diabetes.

I’ve thought for years that the Village’s Health was a scam. This active investigation might just be the tip of the iceberg.

Here is an excerpt from what I just received from The Villages Health (“TVH”) "we discovered a problem with some of our Medicare billing practices. Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that
beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly.
With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to
starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH."

[Bogie Shooter]

Here is an excerpt from what I just received from The Villages Health (“TVH”) "we discovered a problem with some of our Medicare billing practices. Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that
beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly.
With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to
starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH."
I received the same text message. Appears they are doing the right thing.

[golfing eagles]

Here is an excerpt from what I just received from The Villages Health (“TVH”) "we discovered a problem with some of our Medicare billing practices. Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that
beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly.
With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to
starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH."

And now let's add the rest of the statement-----This event did not impact any patient care OR ANY PATIENT BILLING This is not uncommon with EMRs, they found a problem, notified CMS and will pay any overpayments back. I doubt the DOJ is even involved, and I'm 99.9999% sure the OP was scammed/phished.

[OrangeBlossomBaby]

And now let's add the rest of the statement-----This event did not impact any patient care OR ANY PATIENT BILLING This is not uncommon with EMRs, they found a problem, notified CMS and will pay any overpayments back. I doubt the DOJ is even involved, and I'm 99.9999% sure the OP was scammed/phished.

That's why I was pretty sure they were scammed. I got the same notification, and then went to the Villages Health's actual website and logged in to my account and checked my messages and saw that there, confirming that the e-mail notification and text message I received from TVH were legit.

And since they're legit, it means - the DOJ wouldn't be asking ME anything about MY health, to confirm or dispute anything TVH is or is not doing with their Medicare billing. Of course, anyone from the DOJ checking with me about MY Medicare billing info would be obviously lying since I'm not on Medicare in the first place.

But anyway - the DOJ won't call people on the phone to ask them about their health. It's clearly a scam. Just like when you get a call from the IRS saying you'll be going to jail unless you cough up your overdue fines. It's a scam.

[tophcfa]

Sounds like someone is trying to scam the OP. That being said, I wouldn’t be surprised if The Villages Health is being looked at closely. I’ve never heard of another health care operation that serves a senior population and won’t accept Medigap plans. Something about that smells very rotten.

[charlie1]

Definitely a scam! The DOJ would not discuss the issue about anyone's individual case without asking question first to identify the person 100% the person they want to talk with. Just because you answer the phone does not mean you are the person. These initial questions could be enough to get valuable information that they could use. Heck, even in the doctors/dentist/etc office they always ask for some information when you are there in person! I would suggest anyone getting a call ask for a VERIFIABLE DOJ telephone number or website that you can use to gather information on your own about thier investigation before answering any questions!

[Bogie Shooter]

Sounds like someone is trying to scam the OP. That being said, I wouldn’t be surprised if The Villages Health is being looked at closely. I’ve never heard of another health care operation that serves a senior population and won’t accept Medigap plans. Something about that smells very rotten.

Why won’t they accept Medigap plans?

[Caymus]

Don't all Federal Agencies only correspond by US Mail?

[RoadToad]

And exactly how did they get scammed and what did they get scammed out of? They didn't say they gave them information, they already had their medical records so they would have had to scam someone else that had the records.

".. Most conditions were not correct .."

They collected this....

[Rwirish]

Billing issues occurred per TVH. You were scammed as DOJ investigators would not have called you.

[Shelbyh]

Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health. I first thought it was a scam, but after hearing the personal information they had on our records, I was inclined to cooperate with their inquires.

They mostly wanted to confirm conditions listed in our files and confirm they were correct. Most conditions were not correct, especially type 2 diabetes.

I’ve thought for years that the Village’s Health was a scam. This active investigation might just be the tip of the iceberg.

From my experience with this situation, I have never heard of the DOJ conducting this type of investigation by calling patients to verify PIH. CMS would more likely look into this and not by calling you. I’m suspicious. If it was me I would have hung up or contacted the AG to discuss.

[christine J Toft]

Letters went from TVH by email stating they were having an issue that's got government agencies involved. They have to pay back Medicare. I'm guessing these are not simple mistakes.

[golfing eagles]

Sounds like someone is trying to scam the OP. That being said, I wouldn’t be surprised if The Villages Health is being looked at closely. I’ve never heard of another health care operation that serves a senior population and won’t accept Medigap plans. Something about that smells very rotten.

Rotten??? Really???? How so????

Every health care provider has the right to decide which insurances they will and will not accept. We reviewed this every year when the contracts came around. So did every other practice in the country. Sorry you "never heard of this". It is neither "rotten" nor cause for TVH to be "looked at closely", I always wonder where people get these ideas from.

[Triker]

Having done medical billing before! You definitely have to watch it very close here.
Same procedure, twice in a year, same facility, same Dr , same anesthesiologist, same etc
billed two completely different ways.

[golfing eagles]

Letters went from TVH by email stating they were having an issue that's got government agencies involved. They have to pay back Medicare. I'm guessing these are not simple mistakes.

And I'm guessing they are simple mistakes, typically generated by EMR coding, and HIGHLY UNLIKELY to be intentional.

Read the letter----TVH conducted their own internal review, which is something most practices do----we would review each others coding and documentation to spot any problems. Having found "something". they then hired outside consultants to look into it further. "Government agencies", probably CMS (Center for Medicare Services), are required to be notified of any irregularity along these lines. THERE IS NO CONSPIRACY TO DEFRAUD PATIENTS, THIS IS NOT UNUSUAL AT ALL.

If jumping to conclusions without any knowledge of the processes involved were an Olympic sport, this thread would have multiple gold medal winners. And I would like to upgrade my assessment of the OPs chance of being scammed from 99.9999% to 100%.

[crash]

Pretty sure you just got scammed by people taking advantage of billing errors and pretending to be members of the Dept. of Justice.
Got a letter from Villages Health saying there were billing discrepancies and they were working them through to come up with how much they were going to have pay back so not a scam.

[golfing eagles]

Having done medical billing before! You definitely have to watch it very close here.
Same procedure, twice in a year, same facility, same Dr , same anesthesiologist, same etc
billed two completely different ways.

You have to watch all kinds of billing, everywhere. Mistakes happen----it does not constitute a conspiracy to defraud.

If you read the letter, no patient billing was affected by this event---meaning no one was "ripped off" or overpaid. This is most likely a glitch in the electronic submission of billing and coding between TVH and CMS with ABSOLUTELY NO EFFECT on patients or their pocketbooks

[golfing eagles]

Got a letter from Villages Health saying there were billing discrepancies and they were working them through to come up with how much they were going to have pay back so not a scam.

I think the gist of this thread is that the OP, having claimed to received phone calls from the DOJ asking to "verify" his health information is clearly a scam. No federal authority contacts anyone other than by snail mail. This goes especially for the IRS, where scams are a dime a dozen and yet people fall for them.

[MikeN]

I hope you didn’t give them any additional information. Confirm what they had only and request an in person meeting so you can make sure who you are talking to

[Bogie Shooter]

Rotten??? Really???? How so????

Every health care provider has the right to decide which insurances they will and will not accept. We reviewed this every year when the contracts came around. So did every other practice in the country. Sorry you "never heard of this". It is neither "rotten" nor cause for TVH to be "looked at closely", I always wonder where people get these ideas from.

And I'm guessing they are simple mistakes, typically generated by EMR coding, and HIGHLY UNLIKELY to be intentional.

Read the letter----TVH conducted their own internal review, which is something most practices do----we would review each others coding and documentation to spot any problems. Having found "something". they then hired outside consultants to look into it further. "Government agencies", probably CMS (Center for Medicare Services), are required to be notified of any irregularity along these lines. THERE IS NO CONSPIRACY TO DEFRAUD PATIENTS, THIS IS NOT UNUSUAL AT ALL.

If jumping to conclusions without any knowledge of the processes involved were an Olympic sport, this thread would have multiple gold medal winners. And I would like to upgrade my assessment of the OPs chance of being scammed from 99.9999% to 100%.

:agree:

[PugMom]

i got an email telling me of a breach that was found in the code & billing sections. email also states it does & did not affect the treatments of medical care & standards

[Bogie Shooter]

Got a letter from Villages Health saying there were billing discrepancies and they were working them through to come up with how much they were going to have pay back so not a scam.

When you get the call, hang up.

[bowlingal]

The Villages Health ( primary care docs) only use Medicare Advantage. Only the specialists within the Villages Health use traditional Medicare. Why would the Department of Justice be calling about a Medicare issue? Wouldn't it be another agency, if at all? Don't ever believe your caller ID. Have them send you something in the mail.

[golfing eagles]

i got an email telling me of a breach that was found in the code & billing sections. email also states it does & did not affect the treatments of medical care & standards

I suggest you read that e-mail again, and then retract your post.

The letter states ABSOLUTELY NOTHING about a "breach"

It specifically stated that patient care and billing WAS NOT AFFECTED

[FredMitchell]

I would recommend that you set your phone to not accept calls from numbers that are not in your Contacts. Then at best, some random caller can only leave a voice mail. Scammers generally don't have time for that and move on.

Legitimate callers will leave a message and you can return a call, if you want to. Scammers will rarely have a number for a return call. That leaves them open to more law enforcement risk.

Of course, this assumes that you are not using an old fashioned land-line.

Regardless of what type of phone(s) you use, enter the number into the do not call registry. It is a federal offense - extremely rarely enforced - for a caller to violate.

FYI, you can look up your contact info. It was illegally published, likely many times, months ago. Research how to do it. Then put a stop on all credit searches with all credit agencies. At the same time, have them remove all previous addresses.

[G.R.I.T.S.]

Hang up!

[dshoberg]

Here is an excerpt from what I just received from The Villages Health (“TVH”) "we discovered a problem with some of our Medicare billing practices. Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that
beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly.
With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to
starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH."
I received the same email...

[1golfergal]

And now let's add the rest of the statement-----This event did not impact any patient care OR ANY PATIENT BILLING This is not uncommon with EMRs, they found a problem, notified CMS and will pay any overpayments back. I doubt the DOJ is even involved, and I'm 99.9999% sure the OP was scammed/phished.

Yep. I worked for them... they don't call. DUH! They will, however, do in-person interviews.... I mean, seriously, how would they know who is on the other end of the phone?
PHISHING..... hang in there... call #2 is coming:

[virtualcynthia]

Call the Villages health, explain what happened and ask how you can protect yourself from Medical Identity Theft. Check your bills for any unusual charges. Freeze your credit reports.

The moral of the story is never give information over the phone unless you initiated the call. Don’t use any number they give you. Hang up and call the source directly.

[Pat2015]

Here is an excerpt from what I just received from The Villages Health (“TVH”) "we discovered a problem with some of our Medicare billing practices. Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that
beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly.
With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to
starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH."
Oftentimes it’s not the provider that discovered they were billing incorrectly as it’s CMS that flags them based on billings. TV says they are working with federal agencies which I’m certain they are based on overpayments. There is a possibility that an investigation has been opened up and the charges for services that shouldn’t have been billed are being considered as a civil fraud matter by DOJ. Sounds like they may have billed for services not rendered, or unnecessary tests and put in an incorrect diagnosis (in the OP’s case diabetes) to justify that. It will be interesting to see how this ends up playing out.

[Justputt]

The DOJ would not be involved. You've been scammed. I've been involved in many cases where there were disputes with Medicare, including a full-blown RAC audit for every patient we treated with a specific kind of radiation therapy was called into question involving just under $1M. We won all but 1 case where the technique was used. Medicare interpretations are also inconsistent, and we've had to argue many times why a women's breast cancer couldn't be hypo-fractionated and depending on who does the peer-to-peer, sometimes we prevail and sometimes not, and when "not" the Medicare peer we find to be some pediatrician with zero radiotherapy training is just following a script! Medicare is the government, and they do screw up!

[elshackovillages]

Because they are not required to. Seems they make their money taking only advantage plan holders.

[Pat2015]

Letters went from TVH by email stating they were having an issue that's got government agencies involved. They have to pay back Medicare. I'm guessing these are not simple mistakes.
I agree as I think it may be looked at as a potential fraud issue and not simple mistakes. I am also not convinced that this is something TV caught and reported vs an audit that flagged them by CMS at which time an investigation got opened up.

[Pat2015]

The DOJ would not be involved. You've been scammed. I've been involved in many cases where there were disputes with Medicare, including a full-blown RAC audit for every patient we treated with a specific kind of radiation therapy was called into question involving just under $1M. We won all but 1 case where the technique was used. Medicare interpretations are also inconsistent, and we've had to argue many times why a women's breast cancer couldn't be hypo-fractionated and depending on who does the peer-to-peer, sometimes we prevail and sometimes not, and when "not" the Medicare peer we find to be some pediatrician with zero radiotherapy training is just following a script! Medicare is the government, and they do screw up!
Actually DOJ and CMS both investigate Medicare fraud and in this case TV has already admitted that they overbilled so I don’t see where the government is at fault here.

[OrangeBlossomBaby]

Oftentimes it’s not the provider that discovered they were billing incorrectly as it’s CMS that flags them based on billings. TV says they are working with federal agencies which I’m certain they are based on overpayments. There is a possibility that an investigation has been opened up and the charges for services that shouldn’t have been billed are being considered as a civil fraud matter by DOJ. Sounds like they may have billed for services not rendered, or unnecessary tests and put in an incorrect diagnosis (in the OP’s case diabetes) to justify that. It will be interesting to see how this ends up playing out.

They did not commit fraud, they didn't try to commit fraud. NO PATIENT BILLING was compromised. There is no investigation, the DOJ is not involved. It is strictly a coding error that caused TVH to get too much money, and working "with federal agencies" means working with Medicare, to make sure the error is fixed and the money returned to the Medicare fund.

There is nothing interesting about it, and everyone who is a patient at TVH has received the e-mail explaining exactly what happened and exactly what's being done to correct it.

[OrangeBlossomBaby]

Sounds like someone is trying to scam the OP. That being said, I wouldn’t be surprised if The Villages Health is being looked at closely. I’ve never heard of another health care operation that serves a senior population and won’t accept Medigap plans. Something about that smells very rotten.

Dedicated HMO groups and Concierge groups don't accept Medigap plans. There are lots of them.

[Rheinl271]

There was an article in 12/31 Wall St Journal about United Health Care Medicare advantage adding diagnoses to patients records. The more diseases they can reference for a patient the more the doctors and UHC get paid monthly by Medicare. The article specifically mentions a case in the Villages Health Care where they listed a body builder as morbidly obese! The Villages HC refused to comment. My wife is quite active and healthy, but her VHC medical record sounds like a train wreck. This is in fact overbilling Medicare and is likely fraud. Wouldn't be surprised DOJ is investigating and VHC is coming clean.

This is happening across UHC to the tune of $4.6 Billion from 2019 to 2022. Not unique to UHC, but they are the worst offenders. Apparently UHC patients are several times sicker than original Medicare. Apparently, the Govt set this system up for Medicare Advantage insurers to be paid more for sicker patients. Any system can be gamed. And it will be.

[spinner1001]

And now let's add the rest of the statement-----This event did not impact any patient care OR ANY PATIENT BILLING This is not uncommon with EMRs, they found a problem, notified CMS and will pay any overpayments back. I doubt the DOJ is even involved, and I'm 99.9999% sure the OP was scammed/phished.

Agreed. And since TOTV messages are public, bad actors now can learn that OP is susceptible to being scammed and do him/her more harm. (Don’t scoff. AI/ bots scrape websites like this for information.)

I suggest OP ask the website administrators to delete this thread for OP’s protection.

[Pat2015]

They did not commit fraud, they didn't try to commit fraud. NO PATIENT BILLING was compromised. There is no investigation, the DOJ is not involved. It is strictly a coding error that caused TVH to get too much money, and working "with federal agencies" means working with Medicare, to make sure the error is fixed and the money returned to the Medicare fund.

There is nothing interesting about it, and everyone who is a patient at TVH has received the e-mail explaining exactly what happened and exactly what's being done to correct it.
How do you know there is no investigation or potential fraud

[OrangeBlossomBaby]

And exactly how did they get scammed and what did they get scammed out of? They didn't say they gave them information, they already had their medical records so they would have had to scam someone else that had the records.

Scammer - got access to your name, phone number, and the fact that you are on Medicare. Purchased the information probably from some other scammer who harvested the info when you signed up for something online.

So they call and say what they say. You answer the questions. Now they know what medical conditions you have, where you buy your prescriptions, and who your doctor is. They know where you are, and how often you see your doctor and how often he prescribes those meds for those conditions.

So now they can plug all that info into THEIR system - and submit bills to Medicare on behalf of a doctor, who may or may not exist, using your actual doctor's bonafides, and Medicare pays them for doctor visits that never happened, to treat legitimate conditions of a legitimate patient that they already know about and are in their system. Another way would be to counterfeit prescription pads and have drugs sent to them in your name, for conditions they already have in their system and know to expect you to use. If you're unlucky, those drugs will have yearly, quarterly, or monthly limits - and if the scammers tap out your yearly allotment, it means you won't be able to get the drugs you need when you need them.

That's just two ways to scam you. Medicare fraud is BIG business. It costs Americans around $60 Billion per year.

[Bogie Shooter]

Because they are not required to. Seems they make their money taking only advantage plan holders.

What post is this referring to?

[BlueStarAirlines]

Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health.

Definitely a scam. There are never two investigators for a phone call. In person-yes, but there is just one needed for an investigation call since it is recorded.

[Bogie Shooter]

They did not commit fraud, they didn't try to commit fraud. NO PATIENT BILLING was compromised. There is no investigation, the DOJ is not involved. It is strictly a coding error that caused TVH to get too much money, and working "with federal agencies" means working with Medicare, to make sure the error is fixed and the money returned to the Medicare fund.

There is nothing interesting about it, and everyone who is a patient at TVH has received the e-mail explaining exactly what happened and exactly what's being done to correct it.

This is a good summary of the above posts.
Both the stupid posts and those giving valid information.

[Pat2015]

They did not commit fraud, they didn't try to commit fraud. NO PATIENT BILLING was compromised. There is no investigation, the DOJ is not involved. It is strictly a coding error that caused TVH to get too much money, and working "with federal agencies" means working with Medicare, to make sure the error is fixed and the money returned to the Medicare fund.

There is nothing interesting about it, and everyone who is a patient at TVH has received the e-mail explaining exactly what happened and exactly what's being done to correct it.
You seem to know a lot about this. They did not commit fraud; there is no investigation; this was a coding error; etc. How do you know these things?

[Debbraham]

Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health. I first thought it was a scam, but after hearing the personal information they had on our records, I was inclined to cooperate with their inquires.

They mostly wanted to confirm conditions listed in our files and confirm they were correct. Most conditions were not correct, especially type 2 diabetes.

I’ve thought for years that the Village’s Health was a scam. This active investigation might just be the tip of the iceberg.

Received an email from villages healthcare that they were cooperating with govt agencies about overpayment to the villages on Medicare. They had hired outside consultants to review how they were doing coding for patients and the coding practices were in error and resulted in the villages being overpaid by Medicare. So it’s probably not a scam but still err on the cautious side…contact villages healthcare to find out more.

[golfing eagles]

Oftentimes it’s not the provider that discovered they were billing incorrectly as it’s CMS that flags them based on billings. TV says they are working with federal agencies which I’m certain they are based on overpayments. There is a possibility that an investigation has been opened up and the charges for services that shouldn’t have been billed are being considered as a civil fraud matter by DOJ. Sounds like they may have billed for services not rendered, or unnecessary tests and put in an incorrect diagnosis (in the OP’s case diabetes) to justify that. It will be interesting to see how this ends up playing out.

Absolutely no evidence of that at all, NONE. They stated they found irregularities and hired an outside consultant. Of course it is based on overpayments, nobody cares about underpayments. How can anyone reach the conclusion from available evidence that they charged for services not rendered??? That they ordered unnecessary tests??? Ridiculous assumption and it actually borders on libel. And remember, the only person to even mention the DOJ was the OP, who has clearly been scammed.

[mpcolonel]

[QUOTE=Kahuna32162;2397677]Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health. I first thought it was a scam, but after hearing the personal information they had on our records, I was inclined to cooperate with their inquires.

They mostly wanted to confirm conditions listed in our files and confirm they were correct. Most conditions were not correct, especially type 2 diabetes.

I’ve thought for years that the Village’s Health was a scam. This active investigation might just be the tip of the iceberg.[/QUOTE
You should never answer even the simplest questions. Ask their name, what office they work out of and if you want to provide them info. Hang up and look up their office number and call them to verify and then answer their question.

[OrangeBlossomBaby]

You seem to know a lot about this. They did not commit fraud; there is no investigation; this was a coding error; etc. How do you know these things?

Because I got the e-mail, and I'm fairly literate, and know how to look things up.

[Pat2015]

This is a good summary of the above posts.
Both the stupid posts and those giving valid information.
The poster presumes a lot about the specifics of the overpayments, and is certain that there is no investigation. We’ll see how this ultimately works out.

[golfing eagles]

The DOJ would not be involved. You've been scammed. I've been involved in many cases where there were disputes with Medicare, including a full-blown RAC audit for every patient we treated with a specific kind of radiation therapy was called into question involving just under $1M. We won all but 1 case where the technique was used. Medicare interpretations are also inconsistent, and we've had to argue many times why a women's breast cancer couldn't be hypo-fractionated and depending on who does the peer-to-peer, sometimes we prevail and sometimes not, and when "not" the Medicare peer we find to be some pediatrician with zero radiotherapy training is just following a script! Medicare is the government, and they do screw up!

Ain't that the truth. Last thing a provider ever wants to do is ask CMS or a Medicare intermediary a question---you get 6 different answers and flagged for potential audit

[Pat2015]

Because I got the e-mail, and I'm fairly literate, and know how to look things up.
So you got an email and know how to look things up and that’s your basis for your comments?

[Fenster]

Google the phone number. Call the local DOJ and US Attorney’s office.

[golfing eagles]

I agree as I think it may be looked at as a potential fraud issue and not simple mistakes. I am also not convinced that this is something TV caught and reported vs an audit that flagged them by CMS at which time an investigation got opened up.

Not likely AT ALL.

[OrangeBlossomBaby]

The poster presumes a lot about the specifics of the overpayments, and is certain that there is no investigation. We’ll see how this ultimately works out.

They
Were
Scammed.

The DOJ doesn't call people on the phone to investigate Medicare fraud, and ask people on the phone for diagnoses or other medical information. They just flat out don't do that. It's not a function of the Department of Justice.

THEY WERE SCAMMED.

Not sure how I can say that any clearer.

[golfing eagles]

They did not commit fraud, they didn't try to commit fraud. NO PATIENT BILLING was compromised. There is no investigation, the DOJ is not involved. It is strictly a coding error that caused TVH to get too much money, and working "with federal agencies" means working with Medicare, to make sure the error is fixed and the money returned to the Medicare fund.

There is nothing interesting about it, and everyone who is a patient at TVH has received the e-mail explaining exactly what happened and exactly what's being done to correct it.

Absolutely!!!! I'm afraid there are only a few "voices of reason" on this thread. The rest seem to be self-proclaimed "experts" with no idea of what they are spouting out about.

[MrFlorida]

The DOJ calling a civilian , now that's a good one !

[golfing eagles]

There was an article in 12/31 Wall St Journal about United Health Care Medicare advantage adding diagnoses to patients records. The more diseases they can reference for a patient the more the doctors and UHC get paid monthly by Medicare. The article specifically mentions a case in the Villages Health Care where they listed a body builder as morbidly obese! The Villages HC refused to comment. My wife is quite active and healthy, but her VHC medical record sounds like a train wreck. This is in fact overbilling Medicare and is likely fraud. Wouldn't be surprised DOJ is investigating and VHC is coming clean.

This is happening across UHC to the tune of $4.6 Billion from 2019 to 2022. Not unique to UHC, but they are the worst offenders. Apparently UHC patients are several times sicker than original Medicare. Apparently, the Govt set this system up for Medicare Advantage insurers to be paid more for sicker patients. Any system can be gamed. And it will be.

And yet, knowing 10,000 times as much as other posters about this subject, I would be surprised if the DOJ was involved at all---perhaps in some investigation about UHC, but not specifically TVH.

Also, what you don't know, is that EMRs automatically calculate BMI based on the patients height and weight, and then spits out a suggested diagnosis of "overweight", "obese", or "morbidly obese". I had a 22 year old triathlete with 11% body fat characterized as "obese", because the BMI calculation in EMRs don't distinguish between muscle and fat weight. What's worse, those Optum "quality assurance" idiots now required me to give the patient a printed handout (from our paperless office) about the dangers of obesity and a diet. If I didn't, I was a "bad doctor". The idiot physicians labelled by Optum as "good" handed this irrelevant information out willy-nilly like a good puppet. What's even more amazing is that just about everyone has bought into this Optum nonsense as if were the gospel truth, or even a good program. In reality it is absolute crap that caters to the least common denominator---kind of like no quack left behind.

[golfing eagles]

You seem to know a lot about this. They did not commit fraud; there is no investigation; this was a coding error; etc. How do you know these things?

She knows the same way that I do---we are EXPERTS in this field, unlike those who have spouted out a bunch of garbage on this thread.

[OrangeBlossomBaby]

How do you know there is no investigation or potential fraud

Actually you're right. There's rampant fraud and the CIA is investigating The Villages Health and all of its Medicare patients for fraud. They've hooked up the satellites from Russia and are beaming signals down with Jewish space lasers to the TVH breakroom microwave, which has cameras in it that record all the documents the illegal alien doctors steal out of the file room on their way to lunch every day.

There. Happy now?

[Pat2015]

Absolutely no evidence of that at all, NONE. They stated they found irregularities and hired an outside consultant. Of course it is based on overpayments, nobody cares about underpayments. How can anyone reach the conclusion from available evidence that they charged for services not rendered??? That they ordered unnecessary tests??? Ridiculous assumption and it actually borders on libel. And remember, the only person to even mention the DOJ was the OP, who has clearly been scammed.
Nothing libel to say that there might be an investigation.

[Pat2015]

Not likely AT ALL.
And you know this how?

[OrangeBlossomBaby]

She knows the same way that I do---we are EXPERTS in this field, unlike those who have spouted out a bunch of garbage on this thread.

My field is investigative journalism. It requires a highly honed and trained set of critical thinking skills, and formal education in separating the wheat from the chaff. I don't always get it right but I can spend hours, days, and even weeks investigating topics of interest. Law, history, and medicine are topics of interest to me. So I can delve pretty deep into medical texts, the bibliographies of those texts, the CDC documentation, FDA documentation - and then if there's an FDA law that seems off, I'll check the history of that law, and then the history of the people who passed the law... when I lived up north I worked a temp job at Yale Hospital and had access to all kinds of medical tidbits of information - and medical law.

When I was in college we took a 4-day trip to Washington DC and spent time on Capitol Hill talking to Congress, Senate, met a few judges, sat in on a symposium with Ralph Nader, visited the Library of Congress. I've sat in on major court cases, including a HUGE murder trial involving a drunk cop who committed murder at the King Arthur Motel in Chelsea (Boston) . Commonwealth v. McLeod :: 1985 :: Massachusetts Supreme Judicial Court Decisions :: Massachusetts Case Law :: Massachusetts Law :: US Law :: Justia (https://law.justia.com/cases/massachusetts/supreme-court/1985/394-mass-727-2.html) I had to look up state laws at the Boston Public Library (this was before the internet was available).

A neighbor wanted to know how her fiancé could legally adopt her son, when her ex-husband was MIA and she couldn't find him to give consent. So I read three out of 17 (at the time) volumes of the Connecticut General Statutes to learn the entire procedure and every law regarding adoptions, paternity, marriage to a woman with children from a former husband, etc.

Reading things and "looking stuff up" is a big hobby that takes most of my time. Education for its own sake is a priority, and has been since I was a little kid.

[Pat2015]

Actually you're right. There's rampant fraud and the CIA is investigating The Villages Health and all of its Medicare patients for fraud. They've hooked up the satellites from Russia and are beaming signals down with Jewish space lasers to the TVH breakroom microwave, which has cameras in it that record all the documents the illegal alien doctors steal out of the file room on their way to lunch every day.

There. Happy now?
Kind of a ridiculous comment. I was a Special Agent for the Federal Government and did Medicare Fraud investigations which is the basis for my comments. Happy now?

[Number 10 GI]

And yet, knowing 10,000 times as much as other posters about this subject, I would be surprised if the DOJ was involved at all---perhaps in some investigation about UHC, but not specifically TVH.

Also, what you don't know, is that EMRs automatically calculate BMI based on the patients height and weight, and then spits out a suggested diagnosis of "overweight", "obese", or "morbidly obese". I had a 22 year old triathlete with 11% body fat characterized as "obese", because the BMI calculation in EMRs don't distinguish between muscle and fat weight. What's worse, those Optum "quality assurance" idiots now required me to give the patient a printed handout (from our paperless office) about the dangers of obesity and a diet. If I didn't, I was a "bad doctor". The idiot physicians labelled by Optum as "good" handed this irrelevant information out willy-nilly like a good puppet. What's even more amazing is that just about everyone has bought into this Optum nonsense as if were the gospel truth, or even a good program. In reality it is absolute crap that caters to the least common denominator---kind of like no quack left behind.

Some years back the Army started cracking down on overweight soldiers, and there were a lot of them that were fat. There was a young soldier in my unit that was a body builder. He had muscles! There wasn't an ounce of fat on him but because of his stocky body and all the muscles he was determined to be overweight due to his height and weight ratio. The unit commander told him he had to lose enough weight to meet the arbitrary height to weight standard or be discharged from the military. The guy nearly starved himself trying to meet the standard but just couldn't do it. Finally, he had enough of the harassment and started writing letters to his congress critters. A medical review stated that he was not overweight, in excellent health, and his fat content was below the standard for a man his age. His "overweight" problem was muscle weight, not fat.

[golfing eagles]

Actually you're right. There's rampant fraud and the CIA is investigating The Villages Health and all of its Medicare patients for fraud. They've hooked up the satellites from Russia and are beaming signals down with Jewish space lasers to the TVH breakroom microwave, which has cameras in it that record all the documents the illegal alien doctors steal out of the file room on their way to lunch every day.

There. Happy now?

You forgot to mention that the "smart" people are wearing tin foil hats:1rotfl::1rotfl::1rotfl:

[golfing eagles]

Nothing libel to say that there might be an investigation.

hence the word "borders"

[golfing eagles]

And you know this how?

Already explained

[golfing eagles]

Kind of a ridiculous comment. I was a Special Agent for the Federal Government and did Medicare Fraud investigations which is the basis for my comments. Happy now?

I'm sorry, but the posts that you have already made would suggest otherwise---so no, not happy

[Jayhawk]

106937

[Pat2015]

I'm sorry, but the posts that you have already made would suggest otherwise---so no, not happy
Well sounds like you’ve got all the answers about me and this matter based on the email you got, and your research. My 20 years as a Federal Agent resulting in multiple Medicare civil fraud settlements and criminal referrals certainly can’t compete with that.

[Cheapbas]

Don't all Federal Agencies only correspond by US Mail?

Yes, they would have contacted you by letter, maybe in person. All the data they have were from massive attacks on institutions.

DONT EVER give account information to an incoming phone call. Decline, block, contact the agency they claim to be representing directly by using information on their official sites.

[Pat2015]

She knows the same way that I do---we are EXPERTS in this field, unlike those who have spouted out a bunch of garbage on this thread.
I actually know quite a bit about Medicare fraud as I was a Federal Agent that investigated Medicare providers for “over billing.” That’s why I said that there might be an ongoing investigation and it will be interesting to see how it will be resolved.

[Aces4]

Well sounds like you’ve got all the answers about me and this matter based on the email you got, and your research. My 20 years as a Federal Agent resulting in multiple Medicare civil fraud settlements and criminal referrals certainly can’t compete with that.

Some of the "critical thinkers" can't critically think past their own experiences. I am tangling with a coding mess on a bill right now and I have to wonder how much of these coding issues are errors or intentionally coded for higher payment.

In my case they admit to the error, still have the bill on my account and it's taking over 2 months to get the mistake corrected. It now has to go to a board to nullify the charge. What a joke! For clarification, this case does not involve the Villages Hospital.

[Pat2015]

Some of the "critical thinkers" can't critically think past their own experiences. I am tangling with a coding mess on a bill right now and I have to wonder how much of these coding issues are errors or intentionally coded for higher payment.

In my case they admit to the error, still have the bill on my account and it's taking over 2 months to get the mistake corrected. It now has to go to a board to nullify the charge. What a joke! For clarification, this case does not involve the Villages Hospital.
Been there with incorrect billings, and it shouldn’t take multiple attempts to get it corrected. Sorry for what you are going through!

[jump4]

The Villages Health won't even accept traditional Medicare Part B. Something's got to be wrong with that! :mad:

Rotten??? Really???? How so????

Every health care provider has the right to decide which insurances they will and will not accept. We reviewed this every year when the contracts came around. So did every other practice in the country. Sorry you "never heard of this". It is neither "rotten" nor cause for TVH to be "looked at closely", I always wonder where people get these ideas from.

[Bogie Shooter]

The poster presumes a lot about the specifics of the overpayments, and is certain that there is no investigation. We’ll see how this ultimately works out.

Yes, we shall see.

[OrangeBlossomBaby]

The Villages Health won't even accept traditional Medicare Part B. Something's got to be wrong with that! :mad:

The Villages Health is a participating provider for regular non-Medicare health insurances of a pretty broad variety, from FloridaBlue to Cigna. The only Medicare-type insurance they accept are some of the Advantage products.

There are private practices that don't accept any insurance at all, and some that will take FloridaBlue, but not UH Medicare, and won't accept any Advantage products at all. And then there are the HMOs, that accept ONLY patients enrolled in THEIR HMO, and no other insurance at all, of any kind.

This is what happens when health care is commercial and for-profit. They don't have to accept any insurance, and they can pick and choose which insurance they'll accept. If they're not "participating providers" then you either pay their prices, or you find a participating provider.

[JanRoberts]

My husband and I are getting texts and emails with a letter explaining what's happening. They aren't requesting any information.

[tophcfa]

Rotten??? Really???? How so????

Every health care provider has the right to decide which insurances they will and will not accept. We reviewed this every year when the contracts came around. So did every other practice in the country. Sorry you "never heard of this". It is neither "rotten" nor cause for TVH to be "looked at closely", I always wonder where people get these ideas from.

Are you aware of other signature health care providers, serving a senior citizen community, that doesn’t accept traditional Medicare?

[Bill14564]

The Villages Health is a participating provider for regular non-Medicare health insurances of a pretty broad variety, from FloridaBlue to Cigna. The only Medicare-type insurance they accept are some of the Advantage products.

There are private practices that don't accept any insurance at all, and some that will take FloridaBlue, but not UH Medicare, and won't accept any Advantage products at all. And then there are the HMOs, that accept ONLY patients enrolled in THEIR HMO, and no other insurance at all, of any kind.

This is what happens when health care is commercial and for-profit. They don't have to accept any insurance, and they can pick and choose which insurance they'll accept. If they're not "participating providers" then you either pay their prices, or you find a participating provider.

A provider that will not take traditional medicare is a poor fit for a community populated primarily by medicare-aged patients.

[golfing eagles]

Well sounds like you’ve got all the answers about me and this matter based on the email you got, and your research. My 20 years as a Federal Agent resulting in multiple Medicare civil fraud settlements and criminal referrals certainly can’t compete with that.

Based on e-mail and research???? NO, not at all. Based on 40 years of medical practice and hospital administration. So, just which "Federal Agency" did you work for?????

[golfing eagles]

I actually know quite a bit about Medicare fraud as I was a Federal Agent that investigated Medicare providers for “over billing.” That’s why I said that there might be an ongoing investigation and it will be interesting to see how it will be resolved.

And yet your posts fail to show any expertise in this area whatsoever.

[golfing eagles]

The Villages Health won't even accept traditional Medicare Part B. Something's got to be wrong with that! :mad:

No, there is ABSOLUTELY NOTHING WRONG WITH THAT. Dealer's choice.

[golfing eagles]

Are you aware of other signature health care providers, serving a senior citizen community, that doesn’t accept traditional Medicare?

To start with, every concierge practice, of which there are hundreds in Florida alone

[golfing eagles]

A provider that will not take traditional medicare is a poor fit for a community populated primarily by medicare-aged patients.

Really???? Seeing as how almost all their providers have a full slate of patients, the facts would tend to disagree with that assumption.

[Lancer]

You got phished

[Danube]

I hope you didn’t give them any additional information. Confirm what they had only and request an in person meeting so you can make sure who you are talking to

Why would you even do that? "Confirming" anything is literally giving out personal information.

Just hang up.

[Danube]

I received the same email...

Over 90% of my business’s incoming email (regular plus via website contact forms) is spam. All kinds.

[Bill14564]

Really???? Seeing as how almost all their providers have a full slate of patients, the facts would tend to disagree with that assumption.

Really. A local provider that doesn't serve the majority of the community is a poor fit.

That doesn't mean they won't have patients:
- a small subset of a very large number of residents can be a significant number of patients
- I have no doubt (though no data) that some number of patients changed their coverage to be accepted by the provider

[BrianL99]

The Villages Health won't even accept traditional Medicare Part B. Something's got to be wrong with that! :mad:

Go to your local Chevrolet Dealer and tell him you want Warranty Service on your Ford.

Different business model. Their business, they get to choose. If I'm not mistaken, for Medicare, it's essentially opt in/opt out for a provider.

[Just jimmy]

Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health. I first thought it was a scam, but after hearing the personal information they had on our records, I was inclined to cooperate with their inquires.

They mostly wanted to confirm conditions listed in our files and confirm they were correct. Most conditions were not correct, especially type 2 diabetes.

I’ve thought for years that the Village’s Health was a scam. This active investigation might just be the tip of the iceberg.

Got a letter from villages health yesterday. They have been aware of this problem for months per the letter. They have an auditor going through everything and have notified Medicare. They are in the process of repaying Medicare. I worked in medical offices up north and we had this problem also it’s a coding problem. Medicare is complicated and we either owed them money or they owed it to my office. Not a scam. I am surprised they reached out to you.

[Aces4]

Based on e-mail and research???? NO, not at all. Based on 40 years of medical practice and hospital administration. So, just which "Federal Agency" did you work for?????

Maybe if one would provide one's own past employment information, who, what, where and when... one would get that answer.

[Aces4]

And yet your posts fail to show any expertise in this area whatsoever.

I'm confused, is this a top-notch physician's statement or one who worked in the accounting department.? Most of the physicians I know had experts in the financial area of their practice. I never saw any Drs. while administrating healthcare or long term disability claims, whether regular insurance or Medicare. :shocked:

[golfing eagles]

Really. A local provider that doesn't serve the majority of the community is a poor fit.

That doesn't mean they won't have patients:
- a small subset of a very large number of residents can be a significant number of patients
- I have no doubt (though no data) that some number of patients changed their coverage to be accepted by the provider

So they found their niche

[Aces4]

Go to your local Chevrolet Dealer and tell him you want Warranty Service on your Ford.

Different business model. Their business, they get to choose. If I'm not mistaken, for Medicare, it's essentially opt in/opt out for a provider.

Sure there are options, but as stated earlier, this is a poor business model for an aged community which requires the services Medicare covers and provides.

[jump4]

I received the following message via text at 1pm yesterday:
"Dear Valued Patient,
I’m writing to let all The Villages Health (“TVH”) patients know that during a recent review of our billing procedures, we discovered a problem with some of our Medicare billing practices. As part of TVH’s absolute commitment to transparency amongst our patient community, I am sharing this information with you now that we have examined the issue, and have already started to take meaningful action to correct it. But the most important thing we want to impart to all of you is that this billing issue has in no way negatively affected any TVH patients’ medical bills or patient care.
Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly. With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. I cannot stress enough to each and every one of our patients that this issue has in no way affected any patient treatment or medical bills. Rather, this was an internal coding issue that unintentionally resulted in inaccurate payments received by TVH for its medical care. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH. At TVH, our mission to provide the highest quality patient-centered care remains at the very core of all that we do. As always, we will continue to assess ways to improve our processes and services in support of our patients and our community, and we will strive to keep you as informed as possible to maintain our commitment to trust and transparency. On behalf of all of us here at The Villages Health, we wish you a happy and healthy New Year.
Sincerely, Bob Trinh Chief Executive Officer"

Was The Villages Health under some pressure to disclose this, while also attempting to bury it with a pre-holiday release? The timing of this disclosure is noteworthy as the WSJ investigatory article about Medicare Advantage Plans, published just a couple of days ago, cited a “Suspicious” case at The Villages Health. It seems likely to me that The Villages Health is one of several parties under investigation for Medicare Fraud.

Excerpts from the WSJ article:
"Like most doctors, Nicholas Jones prefers to diagnose patients after examining them. When he worked for UnitedHealth Group, though, the company frequently prepared him a checklist of potential diagnoses before he ever laid eyes on them.
UnitedHealth only did that with the Eugene, Ore., family physician’s Medicare Advantage recipients, he said, and its software wouldn’t let him move on to his next patient until he weighed in on each diagnosis.
The diagnoses were often irrelevant or wrong, Jones said. UnitedHealth sometimes suggested a hormonal condition, secondary hyperaldosteronism, that was so obscure Jones had to turn to Google for help. “I needed to look it up,” he said.
The government’s Medicare Advantage system, which uses private insurers to provide health benefits to seniors and disabled people, pays the companies based on how sick patients are, to cover the higher costs of sicker patients. Medicare calculates sickness scores from information supplied by doctors and submitted by the insurers. In the case of UnitedHealth, many of those doctors work directly for UnitedHealth.
More diagnoses make for higher scores—and larger payments. A Wall Street Journal analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers.
Patients examined by doctors working for UnitedHealth, an industry pioneer in directly employing large numbers of physicians, had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans, according to the Journal’s analysis of Medicare data between 2019 and 2022.
...
In a series of articles this year, the Journal has examined the practices of Medicare Advantage companies, including UnitedHealth, the largest. Among other things, the articles showed how diagnoses added by insurers increased payments from the government.

...
Suspicious patient
Chris Henretta, a UnitedHealth Medicare Advantage plan member who lives in The Villages, a retirement community in central Florida, was suspicious when his primary-care doctor diagnosed him as morbidly obese during his annual exam in October.
He is a lifelong weightlifter, plays water volleyball five times a week and has an athletic build.
“I told her I didn’t think I was obese,” Henretta said. When she recorded morbid obesity anyway, he said, he began to “suspect my doctor may have a financial incentive to portray people as higher risk.”
The diagnosis can trigger payments of about $2,400 a year to Medicare Advantage insurers.
A widely used measure to diagnose obesity, body-mass index, has been criticized for sometimes mischaracterizing muscular people as overweight. Henretta’s medical record shows that even by that standard, he didn’t qualify as morbidly obese. His BMI was 32.3 at the time of his October visit, nearly three points below the minimum threshold for morbid obesity.
Henretta’s doctor at The Villages Health, a clinic that contracts with UnitedHealth, also diagnosed him with qualitative platelet disorder, a condition that affects blood clotting.
Henretta said his doctor added the diagnosis after he agreed that his blood seemed to clot slightly more slowly after he started taking baby aspirin several years earlier. His doctor had recommended the baby aspirin after he was diagnosed, in 2021, with aortic atherosclerosis—which could trigger Medicare payments of about $2,700 a year at the time.
Dr. Rachel Bercovitz, a hematologist and professor at Northwestern University’s medical school, said aspirin inhibits platelet function, so Henretta’s doctor is “diagnosing the intended effect of the medication” as a separate disease.
A qualitative platelet disorder diagnosis can trigger extra payments of about $2,000 a year to insurers.
The Villages Health, its top executives and Henretta’s doctor didn’t respond to phone calls and emails requesting comment.
...
Like other Medicare Advantage companies, UnitedHealth also contracts with outside doctors in ways that can increase their payments when they diagnose more conditions. That includes arrangements where doctors receive a portion of the Medicare payments insurers get for their patients. Other Medicare Advantage insurers also suggest diagnoses to independent doctors examining their patients.

Full WSJ article at: wsj.com (https://www.wsj.com/health/healthcare/unitedhealth-medicare-payments-doctors-c2a343db?st=yERAAh&reflink=desktopwebshare_permalink)



There was an article in 12/31 Wall St Journal about United Health Care Medicare advantage adding diagnoses to patients records. The more diseases they can reference for a patient the more the doctors and UHC get paid monthly by Medicare. The article specifically mentions a case in the Villages Health Care where they listed a body builder as morbidly obese! The Villages HC refused to comment. My wife is quite active and healthy, but her VHC medical record sounds like a train wreck. This is in fact overbilling Medicare and is likely fraud. Wouldn't be surprised DOJ is investigating and VHC is coming clean.

This is happening across UHC to the tune of $4.6 Billion from 2019 to 2022. Not unique to UHC, but they are the worst offenders. Apparently UHC patients are several times sicker than original Medicare. Apparently, the Govt set this system up for Medicare Advantage insurers to be paid more for sicker patients. Any system can be gamed. And it will be.

[GoldenBoy]

A provider that will not take traditional medicare is a poor fit for a community populated primarily by medicare-aged patients.

Maybe, they just don't want to spend time listening to entitled old people whining about, well everything. That could be.

[golfing eagles]

I received the following message via text at 1pm yesterday:
"Dear Valued Patient,
I’m writing to let all The Villages Health (“TVH”) patients know that during a recent review of our billing procedures, we discovered a problem with some of our Medicare billing practices. As part of TVH’s absolute commitment to transparency amongst our patient community, I am sharing this information with you now that we have examined the issue, and have already started to take meaningful action to correct it. But the most important thing we want to impart to all of you is that this billing issue has in no way negatively affected any TVH patients’ medical bills or patient care.
Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly. With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. I cannot stress enough to each and every one of our patients that this issue has in no way affected any patient treatment or medical bills. Rather, this was an internal coding issue that unintentionally resulted in inaccurate payments received by TVH for its medical care. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH. At TVH, our mission to provide the highest quality patient-centered care remains at the very core of all that we do. As always, we will continue to assess ways to improve our processes and services in support of our patients and our community, and we will strive to keep you as informed as possible to maintain our commitment to trust and transparency. On behalf of all of us here at The Villages Health, we wish you a happy and healthy New Year.
Sincerely, Bob Trinh Chief Executive Officer"

Was The Villages Health under some pressure to disclose this, while also attempting to bury it with a pre-holiday release? The timing of this disclosure is noteworthy as the WSJ investigatory article about Medicare Advantage Plans, published just a couple of days ago, cited a “Suspicious” case at The Villages Health. It seems likely to me that The Villages Health is one of several parties under investigation for Medicare Fraud.

Excerpts from the WSJ article:
"Like most doctors, Nicholas Jones prefers to diagnose patients after examining them. When he worked for UnitedHealth Group, though, the company frequently prepared him a checklist of potential diagnoses before he ever laid eyes on them.
UnitedHealth only did that with the Eugene, Ore., family physician’s Medicare Advantage recipients, he said, and its software wouldn’t let him move on to his next patient until he weighed in on each diagnosis.
The diagnoses were often irrelevant or wrong, Jones said. UnitedHealth sometimes suggested a hormonal condition, secondary hyperaldosteronism, that was so obscure Jones had to turn to Google for help. “I needed to look it up,” he said.
The government’s Medicare Advantage system, which uses private insurers to provide health benefits to seniors and disabled people, pays the companies based on how sick patients are, to cover the higher costs of sicker patients. Medicare calculates sickness scores from information supplied by doctors and submitted by the insurers. In the case of UnitedHealth, many of those doctors work directly for UnitedHealth.
More diagnoses make for higher scores—and larger payments. A Wall Street Journal analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers.
Patients examined by doctors working for UnitedHealth, an industry pioneer in directly employing large numbers of physicians, had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans, according to the Journal’s analysis of Medicare data between 2019 and 2022.
...
In a series of articles this year, the Journal has examined the practices of Medicare Advantage companies, including UnitedHealth, the largest. Among other things, the articles showed how diagnoses added by insurers increased payments from the government.

...
Suspicious patient
Chris Henretta, a UnitedHealth Medicare Advantage plan member who lives in The Villages, a retirement community in central Florida, was suspicious when his primary-care doctor diagnosed him as morbidly obese during his annual exam in October.
He is a lifelong weightlifter, plays water volleyball five times a week and has an athletic build.
“I told her I didn’t think I was obese,” Henretta said. When she recorded morbid obesity anyway, he said, he began to “suspect my doctor may have a financial incentive to portray people as higher risk.”
The diagnosis can trigger payments of about $2,400 a year to Medicare Advantage insurers.
A widely used measure to diagnose obesity, body-mass index, has been criticized for sometimes mischaracterizing muscular people as overweight. Henretta’s medical record shows that even by that standard, he didn’t qualify as morbidly obese. His BMI was 32.3 at the time of his October visit, nearly three points below the minimum threshold for morbid obesity.
Henretta’s doctor at The Villages Health, a clinic that contracts with UnitedHealth, also diagnosed him with qualitative platelet disorder, a condition that affects blood clotting.
Henretta said his doctor added the diagnosis after he agreed that his blood seemed to clot slightly more slowly after he started taking baby aspirin several years earlier. His doctor had recommended the baby aspirin after he was diagnosed, in 2021, with aortic atherosclerosis—which could trigger Medicare payments of about $2,700 a year at the time.
Dr. Rachel Bercovitz, a hematologist and professor at Northwestern University’s medical school, said aspirin inhibits platelet function, so Henretta’s doctor is “diagnosing the intended effect of the medication” as a separate disease.
A qualitative platelet disorder diagnosis can trigger extra payments of about $2,000 a year to insurers.
The Villages Health, its top executives and Henretta’s doctor didn’t respond to phone calls and emails requesting comment.
...
Like other Medicare Advantage companies, UnitedHealth also contracts with outside doctors in ways that can increase their payments when they diagnose more conditions. That includes arrangements where doctors receive a portion of the Medicare payments insurers get for their patients. Other Medicare Advantage insurers also suggest diagnoses to independent doctors examining their patients.

Full WSJ article at: wsj.com (https://www.wsj.com/health/healthcare/unitedhealth-medicare-payments-doctors-c2a343db?st=yERAAh&reflink=desktopwebshare_permalink)

Very interesting. 32.3 is the definition of "obese" but not "morbidly obese", which requires a BMI of 35+. And platelet dysfunction as a diagnosis for a patient on aspirin is a stretch. That being said, one patient of 1 doctor does not constitute a systemic conspiracy to defraud Medicare.

[golfing eagles]

Maybe, they just don't want to spend time listening to entitled old people whining about, well everything. That could be.

Sorry, but just about every patient of every age whines about everything. It's OK, it comes with the territory

[MSGirl]

Just received a call from from 2 people who identified themselves as investigators for the Department of Justice, looking into Medicare billing practices at the village’s health. I first thought it was a scam, but after hearing the personal information they had on our records, I was inclined to cooperate with their inquires.

They mostly wanted to confirm conditions listed in our files and confirm they were correct. Most conditions were not correct, especially type 2 diabetes.

I’ve thought for years that the Village’s Health was a scam. This active investigation might just be the tip of the iceberg.

Oh no! I’m afraid you have been scammed. The government will not call you on the phone and identify themselves as government officials without proof. Did you at least check the incoming phone number to see where it came from?
The Villages sent out their own message explaining what they themselves found and were taking measures to correct it! Doesn’t affect us. But I’m sorry that you gave unknown caller personal information.

[Aces4]

Maybe, they just don't want to spend time listening to entitled old people whining about, well everything. That could be.

Or perhaps some old people consider themselves elite and should have better healthcare than everyone else.:1rotfl::1rotfl::1rotfl:

[Aces4]

Sorry, but just about every patient of every age whines about everything. It's OK, it comes with the territory

I, personally, wouldn't want a physician who thinks most patients whine about everything. barf

[Aces4]

Very interesting. 32.3 is the definition of "obese" but not "morbidly obese", which requires a BMI of 35+. And platelet dysfunction as a diagnosis for a patient on aspirin is a stretch. That being said, one patient of 1 doctor does not constitute a systemic conspiracy to defraud Medicare.

You right, but it can constitute the tip of the iceberg...

[golfing eagles]

I, personally, wouldn't want a physician who thinks most patients whine about everything. barf

Just relaying the reality of medical practice. We all know it to be true, but again, it comes with the territory. It does not affect patient care, nor do we concern ourselves with it all that much