Thought’s on Villages Health Chapter 11

[birdawg]

What’s your thoughts on Villages Health filing chapter 11

[Laurawilcox]

With owing millions from the Medicare over billing it may be the only option. Really want them to be successful as we need all of the medical options we can get here. It was interesting the Sun article indicated that all insurance will be accepted during the realignment hope that is true. Beautiful facilities were limited for Medicare patients to only Medicare advantage, hope that changes. May increase their success.

[OrangeBlossomBaby]

With owing millions from the Medicare over billing it may be the only option. Really want them to be successful as we need all of the medical options we can get here. It was interesting the Sun article indicated that all insurance will be accepted during the realignment hope that is true. Beautiful facilities were limited for Medicare patients to only Medicare advantage, hope that changes. May increase their success.

I hope that changes, too. Next year is Medicare time for me, and I wasn't sure I wanted to go the Advantage route. But I worried about having to find a new doctor since I am a TVH patient with normal non-Medicare mundane Marketplace insurance.

If they start accepting regular Medicare plans, I'll have more options, and still be able to keep my own doctors.

[Altavia]

https://news.bloomberglaw.com/bankruptcy-law/villages-health-files-chapter-11-to-sell-assets-to-centerwell

Villages Health Files Chapter 11, to Sell Assets to CenterWell


The Villages Health says it has filed for Chapter 11 bankruptcy in the Middle District of Florida court as part of a strategic restructuring, according to a statement.

Estimated liabilities of $100m-$500m and estimated assets of $50m-$100m, a separate court filing shows Humana Inc’s CenterWell Senior Primary Care entered into a “stalking horse” asset purchase agreement with TVH

Deal provides for CenterWell to acquire TVH’s assets as a going concern, including eight primary care centers and two specialty care centers

TVH will continue to fully operate its business and manage its affairs without interruption during the sale process
TVH ...

[Snowbirdtobe]

In a case like this the court has issued an order to continue the business unchanged. The plan and disclosure statements are due by 10/31/2025 but that is likely to change. So payroll will continue, utilities are prohibited from turning out the lights, everything is likely to remain unchanged for a while.

The Villages Health will have many issues because of the large liabilities outstanding. Who do they stiff and walk away from?
What sort of payments were made before the filing?

[KarenBrake]

Wondering… if this Medicare fraud will lead to some arrest.

[Stu from NYC]

Wondering… if this Medicare fraud will lead to some arrest.

I would sure hope so. How can this happen?

Would think there would be at least some oversight but apparently not.

[tophcfa]

Interesting, but not surprising. The fact that they only accepted certain Advantage plans, and no Medigap plans, for primary care immediately raised the hair on the back of my neck that something fishy was going on. As far as I’m aware, they were the only large health care operation in the country serving a predominantly senior citizen population that wouldn’t accept traditional Medicare. My intuitive suspicions aren’t always correct, but apparently it was this time.

[kingofbeer]

What’s your thoughts on Villages Health filing chapter 11
I was shocked when I read it in the Daily Sun today. I received an urgent text message from Villages Health. The link for that did not work. Maybe they need to pay back money to Medicare which they do not have.

Based on the bankruptcy filing it looks like Morse family no longer wants to finance this unprofitable entity. I had always assumed that Morse family would keep on funding entity which allows them to sell more homes to Medicare eligible people.

"The Villages Health says it has filed for Chapter 11 bankruptcy in the Middle District of Florida court as part of a strategic restructuring, according to a statement.
Estimated liabilities of $100m-$500m and estimated assets of $50m-$100m, a separate court filing shows
Humana Inc’s CenterWell Senior Primary Care entered into a “stalking horse” asset purchase agreement with TVH
Deal provides for CenterWell to acquire TVH’s assets as a going concern, including eight primary care centers and two specialty care centers
TVH will continue to fully operate its business and manage its affairs without interruption during the sale process."

[Rainger99]

Does anyone know who actually owns Villages Health?

The Villages Health System, LLC is owned by The Villages Health Holding Company, LLC, which is part of the Holding Company of The Villages, Inc.

The Holding Company of The Villages, Inc. is a privately-held company, and specific ownership details are not fully disclosed in public records.

[OrangeBlossomBaby]

Wondering… if this Medicare fraud will lead to some arrest.

It wasn't fraud. It was a really huge, significant flaw that TVH discovered, and reported. They were being overpaid for quite awhile. At some point, someone found what the problem was and said "hey boss - this is totally not right." And the boss said "OMG holy crap" and reported it to Medicare, and told Medicare "hey youz guyz - you've been sending us too much money! How do we give it back to you?" And Medicare said "oh golly gee let's figure this out" and they did.

Unfortunately, imposed penalties for overpayment don't get absorbed by the people who were doing the overpayment (Medicare) but by the entity that receives it (TVH). So they're on the hook for the millions in the government's overpayments, AND for penalties. Which - they can't afford.

[Bjeanj]

Did I read the Daily Sun article correctly that The Villages Health incorrectly billed Medicare for hundreds of millions of dollars? If so, how does that happen? It seems like no one is that incompetent? Intentional? Over what time period? The article indicated that The Villages Health was proactive in reporting the overbillings.

[OrangeBlossomBaby]

Did I read the Daily Sun article correctly that The Villages Health incorrectly billed Medicare for hundreds of millions of dollars? If so, how does that happen? It seems like no one is that incompetent? Intentional? Over what time period? The article indicated that The Villages Health was proactive in reporting the overbillings.

Yes if I remember it was some kind of computer error. And Medicare just paid it, over and over again, without once questioning it. It was never flagged. When TVH realized what was happening they immediately reported the error and cooperated with Medicare to repay the overpayments.

[justjim]

It wasn't fraud. It was a really huge, significant flaw that TVH discovered, and reported. They were being overpaid for quite awhile. At some point, someone found what the problem was and said "hey boss - this is totally not right." And the boss said "OMG holy crap" and reported it to Medicare, and told Medicare "hey youz guyz - you've been sending us too much money! How do we give it back to you?" And Medicare said "oh golly gee let's figure this out" and they did.

Unfortunately, imposed penalties for overpayment don't get absorbed by the people who were doing the overpayment (Medicare) but by the entity that receives it (TVH). So they're on the hook for the millions in the government's overpayments, AND for penalties. Which - they can't afford.

TVH was apparently “coding”
many procedures wrong. I don’t know who caught the overpayments. Generally auditors are the ones that first spot such a pattern of overpayments. The best money governments can spend is on more monitors and auditors. Sometimes it’s honest mistakes and sometimes not so much the case.

[Rainger99]

It wasn't fraud. It was a really huge, significant flaw that TVH discovered, and reported. They were being overpaid for quite awhile. At some point, someone found what the problem was and said "hey boss - this is totally not right." And the boss said "OMG holy crap" and reported it to Medicare, and told Medicare "hey youz guyz - you've been sending us too much money! How do we give it back to you?" And Medicare said "oh golly gee let's figure this out" and they did.

Unfortunately, imposed penalties for overpayment don't get absorbed by the people who were doing the overpayment (Medicare) but by the entity that receives it (TVH). So they're on the hook for the millions in the government's overpayments, AND for penalties. Which - they can't afford.

I will say that they have not been very transparent on the overbilling issue. I think they should provide a very detailed explanation. When did it start? Was it one code? A hundred codes? A thousand codes? Were there any audits during the overbilling?

What caused it? And was it a programming error? Did the money go to the doctors or to the owners of the company?

[Stu from NYC]

It wasn't fraud. It was a really huge, significant flaw that TVH discovered, and reported. They were being overpaid for quite awhile. At some point, someone found what the problem was and said "hey boss - this is totally not right." And the boss said "OMG holy crap" and reported it to Medicare, and told Medicare "hey youz guyz - you've been sending us too much money! How do we give it back to you?" And Medicare said "oh golly gee let's figure this out" and they did.

Unfortunately, imposed penalties for overpayment don't get absorbed by the people who were doing the overpayment (Medicare) but by the entity that receives it (TVH). So they're on the hook for the millions in the government's overpayments, AND for penalties. Which - they can't afford.

If TVH was getting overpaid for hundreds of millions of dollars where did the money go? Had to go somewhere.

How did people not know how to code for billing purposes?

I smell fraud

[Stu from NYC]

If TVH was getting overpaid for hundreds of millions of dollars where did the money go? Had to go somewhere.

How did people not know how to code for billing purposes?

I smell fraud

Or as I believe Hamlet said "something is rotten in Denmark".

[OrangeBlossomBaby]

TVH was apparently “coding”
many procedures wrong. I don’t know who caught the overpayments. Generally auditors are the ones that first spot such a pattern of overpayments. The best money governments can spend is on more monitors and auditors. Sometimes it’s honest mistakes and sometimes not so much the case.

TVH caught the mistakes and reported it to Medicare. The miscoding was not intentional - if it was, then yeah it'd be fraud, and TVH would be under criminal investigation. Medicare acknowledged that this was a mistake. A HUGE mistake, but a mistake nonetheless.

[OrangeBlossomBaby]

I will say that they have not been very transparent on the overbilling issue. I think they should provide a very detailed explanation. When did it start? Was it one code? A hundred codes? A thousand codes? Were there any audits during the overbilling?

What caused it? And was it a programming error? Did the money go to the doctors or to the owners of the company?

https://thevillageshealth.com/wp-content/uploads/2024/12/24121698_TVH-Letter-12-30-24-FINAL_1230.pdf

Doctors at TVH don't work on commission. They are salaried. The specific codes are irrelevant, to patients, unless the billing error is affecting their bill. This miscoding didn't affect patient billing at all, and so patients really don't need to hear all the nitty gritty details.

They need to know there was a mistake. The mistake was found, and reported. The mistake was corrected so that it can't happen again. There's a debt that has to be repaid as a result. It's in the process of being repaid.

[Rainger99]

https://thevillageshealth.com/wp-content/uploads/2024/12/24121698_TVH-Letter-12-30-24-FINAL_1230.pdf

Doctors at TVH don't work on commission. They are salaried. The specific codes are irrelevant, to patients, unless the billing error is affecting their bill. This miscoding didn't affect patient billing at all, and so patients really don't need to hear all the nitty gritty details.

They need to know there was a mistake. The mistake was found, and reported. The mistake was corrected so that it can't happen again. There's a debt that has to be repaid as a result. It's in the process of being repaid.

That appears to be a rather vague explanation written by their lawyers. It doesn’t explain what happened.

And for a company that has an “absolute
commitment to transparency amongst our patient community” it clearly lacks transparency.

Is the debt being repaid? I thought they have estimated liabilities of $100m-$500m and estimated assets of $50m-$100m.

[golfing eagles]

It wasn't fraud. It was a really huge, significant flaw that TVH discovered, and reported. They were being overpaid for quite awhile. At some point, someone found what the problem was and said "hey boss - this is totally not right." And the boss said "OMG holy crap" and reported it to Medicare, and told Medicare "hey youz guyz - you've been sending us too much money! How do we give it back to you?" And Medicare said "oh golly gee let's figure this out" and they did.

Unfortunately, imposed penalties for overpayment don't get absorbed by the people who were doing the overpayment (Medicare) but by the entity that receives it (TVH). So they're on the hook for the millions in the government's overpayments, AND for penalties. Which - they can't afford.

100% totally correct. Everything that everybody else posted about this previously was a load of garbage.

[golfing eagles]

I will say that they have not been very transparent on the overbilling issue. I think they should provide a very detailed explanation. When did it start? Was it one code? A hundred codes? A thousand codes? Were there any audits during the overbilling?

What caused it? And was it a programming error? Did the money go to the doctors or to the owners of the company?

And just why do you think you are entitled to that information? This is strictly between CMS and TVH, YOU are not involved.

[golfing eagles]

If TVH was getting overpaid for hundreds of millions of dollars where did the money go? Had to go somewhere.

How did people not know how to code for billing purposes?

I smell fraud

Take another whiff, it was a computer error that went unnoticed for a long time. Once TVH noticed it they immediately notified CMS. NO FRAUD

[Rainger99]

And just why do you think you are entitled to that information? This is strictly between CMS and TVH, YOU are not involved.

One of the parties is CMS which is a federal agency. If it were the plans for the bombing of Iran, I think they should keep that secret - at least while it is in the planning stages.

The case is now in the courts and most court records are public information so we should be entitled to that information. (Perhaps the Daily Sun will do some investigative journalism on the issue.)

Finally, TVH posted a letter saying that they have an “absolute commitment to transparency amongst our patient community.”

[Risuli]

Interesting, but not surprising. The fact that they only accepted certain Advantage plans, and no Medigap plans, for primary care immediately raised the hair on the back of my neck that something fishy was going on. As far as I’m aware, they were the only large health care operation in the country serving a predominantly senior citizen population that wouldn’t accept traditional Medicare. My intuitive suspicions aren’t always correct, but apparently it was this time.

Agree. When we moved here 3 years ago I was shocked that they would not accept our insurance which is medicare along with Blue Cross Blue Shield, but only Advantage plans (but somehow their specialists are OK with it).

[rustyp]

How many of TVH docs are going to stick around after this debacle plays out ? Most docs were there due to being salaried and limited number o patients. If the system changes many TVH patients will take a hike also. This will tax the regular Medicare docs. And you thought the emergency room wait was long. Watch what's next for the entire community.

[Stu from NYC]

Take another whiff, it was a computer error that went unnoticed for a long time. Once TVH noticed it they immediately notified CMS. NO FRAUD

You certainly know more about how this works than the rest of us but where did the money go?

[CoachKandSportsguy]

Take another whiff, it was a computer error that went unnoticed for a long time. Once TVH noticed it they immediately notified CMS. NO FRAUD

just crappy internal / financial auditing, and probably poor data entry training. However, remember, its not fraud if you really believe you are right!

Coding does change over time. . but if TV LLC owned the hospital, most likely the money went to the TV LLC development pot. . .

[OrangeBlossomBaby]

One of the parties is CMS which is a federal agency. If it were the plans for the bombing of Iran, I think they should keep that secret - at least while it is in the planning stages.

The case is now in the courts and most court records are public information so we should be entitled to that information. (Perhaps the Daily Sun will do some investigative journalism on the issue.)

Finally, TVH posted a letter saying that they have an “absolute commitment to transparency amongst our patient community.”

Words and their placement matters.

The words and their placement:

"Absolute commitment to transparency among our patient community."

What that does NOT mean:

Commitment to absolute transparency.

What that also does NOT mean:

Commitment to transparency among anyone beyond their patient community.

They were transparent. They weren't "absolutely" transparent, because the details are none of your business.

Any public information is public. If you want to know the public information, you can put in a FOIA request with the government.

[Cardinal64]

I wonder who wrote that self-serving article in the newspaper owned by the Developer who also owns TVH. The computer didn't cause the error. It submits claims that someone instructs it to. The lack of oversight by TVH and by Medicare in this case is just another example of why Medicare is in trouble nationally. TVH has spent the over-payments as it expanded, and would have been in deep trouble without those funds. You declare bankruptcy to avoid payment of debts, so it looks like Medicare will take the brunt of the loss. Hopefully Sumter County and Florida tax payments are up to date. Let us pray that Centerwell has the internal controls and management skills that will allow the existing facilities and services to survive.

[Stu from NYC]

I wonder who wrote that self-serving article in the newspaper owned by the Developer who also owns TVH. The computer didn't cause the error. It submits claims that someone instructs it to. The lack of oversight by TVH and by Medicare in this case is just another example of why Medicare is in trouble nationally. TVH has spent the over-payments as it expanded, and would have been in deep trouble without those funds. You declare bankruptcy to avoid payment of debts, so it looks like Medicare will take the brunt of the loss. Hopefully Sumter County and Florida tax payments are up to date. Let us pray that Centerwell has the internal controls and management skills that will allow the existing facilities and services to survive.

Thanks think you answered my question as to where the money went. Would hope that the owners of TVH would have to reimburse medicare

[rustyp]

If the miscoding resulted with TVH receiving hundreds of millions of dollars not entitled is it a profitable venture when the dust settles ?

For the record I do not see this as an advantage plan vs Medicare / supplement issue. why couldn't a medicare / supplement establishment miscode ?

[Rainger99]

Take another whiff, it was a computer error that went unnoticed for a long time. Once TVH noticed it they immediately notified CMS. NO FRAUD

At this point, I don’t think we can reach any conclusion as to whether it was a coding error or whether it is fraud.

All we have is a conclusory statement from TVH. I know that corporations “always” tell the truth but I would like to hear more details before I make any final decision as to what happened.

[Pat2015]

Yes if I remember it was some kind of computer error. And Medicare just paid it, over and over again, without once questioning it. It was never flagged. When TVH realized what was happening they immediately reported the error and cooperated with Medicare to repay the overpayments.
Computer error, and never flagged? What’s the basis for your comment? I went round and round with you relative to this back in January when I said that there was probably a DOJ investigation which you said wasn’t the case.

[Pat2015]

I wonder who wrote that self-serving article in the newspaper owned by the Developer who also owns TVH. The computer didn't cause the error. It submits claims that someone instructs it to. The lack of oversight by TVH and by Medicare in this case is just another example of why Medicare is in trouble nationally. TVH has spent the over-payments as it expanded, and would have been in deep trouble without those funds. You declare bankruptcy to avoid payment of debts, so it looks like Medicare will take the brunt of the loss. Hopefully Sumter County and Florida tax payments are up to date. Let us pray that Centerwell has the internal controls and management skills that will allow the existing facilities and services to survive.
Medicare will not take a loss as federal debts are not dischargeable under bankruptcy. Also they filed for reorganization not discharge under Chapter 11 in order to sell the business

[tophcfa]

I am astounded that anyone could possibly believe this was an innocent computer error. I’ve got some swamp land to sell ya that surrounds Alligator Alcatraz if you honestly believe that. Hundreds of millions of dollars were over billed over years, and the $$$ disappeared and isn’t listed as assets in the bankruptcy filling. And then the error was suddenly discovered and self reported, REALLY? Or they knew they were about to get busted and tried to save face and keep from getting thrown in prison by concocting a far fetched story of presumed innocence? If they actual let an innocent computer glitch over bill, and accept 100’s of millions over several years, then they are guilty of gross negligence, incompetence, and lack of any reasonable internal controls. And what happened to all that money, did the computer error miraculously make it disappear? This doesn’t pass even the most lenient of sniff tests.

[biker1]

The Villages Health specifically said it was an issue with “certain billing processes and practices”. I didn’t see them use the term “computer error”.


I am astounded that anyone could possibly believe this was an innocent computer error. I’ve got some swamp land to sell ya that surrounds Alligator Alcatraz if you honestly believe that. Hundreds of millions of dollars were over billed over years, and the $$$ disappeared and isn’t listed as assets in the bankruptcy filling. And then the error was suddenly discovered and self reported, REALLY? Or they knew they were about to get busted and tried to save face and keep from getting thrown in prison by concocting a far fetched story of presumed innocence? If they actual let an innocent computer glitch over bill, and accept 100’s of millions over several years, then they are guilty of gross negligence, incompetence, and lack of any reasonable internal controls. And what happened to all that money, did the computer error miraculously make it disappear? This doesn’t pass even the most lenient of sniff tests.

[BrianL99]

I am astounded that anyone could possibly believe this was an innocent computer error. I’ve got some swamp land to sell ya that surrounds Alligator Alcatraz if you honestly believe that. .

The Villages Health over-billed, in excess of $360,000,000, over a 4 year period.

That's $90,000,000 per year.

They currently have assets of between $50,000,000 - $100,000,000.

The yearly over-billing, exceeded their total assets.

This isn't a simple rounding error that went un-noticed.

How do you not notice an extra $90,000,000 per year in revenue? For 4 years?

If it takes a company's management 5 years, to recognize they're receiving $90M a year more than they deserved, would you trust those morons with your health?

As for the "self-reporting" claims?

What seems to have been forgotten, is Central Health and The Villages Health engaged in merger/stock exchange discussions last year. Those discussions were de-railed by the discovery of the over-billing.

It sounds suspiciously like Central Health discovered the over-billing during their Due Diligence and self-reporting became a necessity ... the cat was out of the bag.

[Rainger99]

I always thought that TVH didn’t take Medicare - only Advantage plans.

I am on Advantage and as far as I know, TVH sends the bills to UHC - not to Medicare. Does anyone know how Medicare could have been over billed?

And if Medicare was over billed, wouldn’t UHC, Blue Cross, etc., also be over billed?

And would the over billing impact patients requiring them to have higher co-pays and deductibles?

[rustyp]

If the miscoding resulted with TVH receiving hundreds of millions of dollars not entitled is it a profitable venture when the dust settles ?

For the record I do not see this as an advantage plan vs Medicare / supplement issue. why couldn't a medicare / supplement establishment miscode ?

The Villages Health doesn't accept regular Medicare/Supplements. It only accepts Medicare Advantage, and it accepts a variety of Marketplace insurance plans for people who aren't old enough for Medicare yet (such as myself).
My question was not aimed at TVH. It was to the posters who refer to an Advantage plan is somehow related to this debacle and it would not happen on Medicare with a supplement. Don't both systems have to code to receive payment ?

[BrianL99]

I always thought that TVH didn’t take Medicare - only Advantage plans.

I am on Advantage and as far as I know, TVH sends the bills to UHC - not to Medicare. Does anyone know how Medicare could have been over billed?

And if Medicare was over billed, wouldn’t UHC, Blue Cross, etc., also be over billed?

And would the over billing impact patients requiring them to have higher co-pays and deductibles?


If you are on a Medicare Advantage Plan, Medicare is still paying for your health care and your Medicare Advantage Plan is managing it for Medicare .... for a %. The actual healthcare provider is essentially a "pass through', but it would seem the insurer must have some liability and/or responsibility for lack of oversight?

It's inconceivable that TV Health could have done almost $100M/year in direct medicare billings, for non-Advantage Emergency Care.

I don't see how BCBS could be involved, as TV Health doesn't accept supplemental insurance.

[BrianL99]

My question was not aimed at TVH. It was to the posters who refer to an Advantage plan is somehow related to this debacle and it would not happen on Medicare with a supplement. Don't both systems have to code to receive payment ?

Someone in the medical business would know better, but I believe the "coding" and billing process is completely different for Advantage insurers, vs Supplemental insurers.

Again, just an educated guess ... with a Supplemental Plan, the consumer/patient is more involved in the process, up and through billing. Depending on the specifics of the supposed "computer error", it's likely that it would have been caught sooner with a Supplemental plan ... the billing is more transparent.

[egmcaninch]

TVH caught the mistakes and reported it to Medicare. The miscoding was not intentional - if it was, then yeah it'd be fraud, and TVH would be under criminal investigation. Medicare acknowledged that this was a mistake. A HUGE mistake, but a mistake nonetheless.
So Medicare was overpaid by TVH millions of dollars? Medicare used those million of dollars for a span of time? Now, Medicare wants to penalize TVH because they got more money than they should have? Don't understand the penalty for getting & using more money...

[RoseyRed]

Just to clarify the TVHCS comment about accepting any insurance. A few years ago, we asked the TVHCS if they accepted my previous employer's UHC plan, which is very good, and they told us NO. Recently, we were surprised when we again asked TVHCS if they accepted our UHC plan, and they said they did. However, once we started to apply and fill in the paperwork, we were then told there were only 2 Primary care doctors in their system that accepted UHC, and it was / and still is months before we could get our first required appointment. They told us that even though it was currently months, after we filled in the paperwork and it was accepted, the appointment could perhaps be changed to a sooner date. Well, after being accepted and calling for a sooner appointment a few times during the last month, nothing opened up, and we just gave up...still waiting. Not sure if this recent announcement has much or anything to do with this. But beware, if you don't have The Villages Health insurance, you will be in for a long 1st appointment wait time for the very limited number of Drs that accept your insurance in their system:cry:
There are other providers in the area besides the TVH. I was turned down from the TVH and went with Orlando which has been fine.

[joshgun]

TVH filed because of over billing Medicare by hundreds of millions. Since TVH only accepts their advantage plans and not traditional Medicare their Advantage plans did not do well. I expect TV Advantage plans will be replaced by Humana plans and traditional Medicare. Also when a company files for bankruptcy employees become concerned about their future and may leave. Humana has to assure the employees and keep them informed.

[oneclickplus]

What’s your thoughts on Villages Health filing chapter 11

They scammed the system (over billing Medicare HUNDREDS OF MILLIONS). This is the fraud and abuse that the current administration is trying to fix. Know that they have or will also over bill patients (you and me) also without even a pause to consider ethics.

What are my thoughts? "Good riddance"

[Andyb]

What’s your thoughts on Villages Health filing chapter 11
Do the crime, do the time.

[Marmaduke]

100% totally correct. Everything that everybody else posted about this previously was a load of garbage.
Okay, so this is may be true.
What a shame they didn't have enough business acumen to have an annual audit by certified auditor.
Even small business operations know to check the books. What am I missing Doc?

[john352]

Does anyone know who actually owns Villages Health?

The Villages Health System, LLC is owned by The Villages Health Holding Company, LLC, which is part of the Holding Company of The Villages, Inc.

The Holding Company of The Villages, Inc. is a privately-held company, and specific ownership details are not fully disclosed in public records.

I checked the property records for The Villages Health building near Sumter Landing; the owner is listed as The Village Operating Company.

[ithos]

I was informed by a well placed source that the inflection point was when they changed the insurance policies and created another layer of management which significantly added to the overhead costs.

[ithos]

Does anyone know how many of the Morse clan works there?

[elevatorman]

This is the site for Centerwell Health that is closest to The Villages. It is about 6 miles from UF Health Spanish Plains (The Villages Hospital). You may get a feel for what to expect if the sale is approved.

The Villages, FL | CenterWell Senior Primary Care (https://www.centerwellprimarycare.com/en/florida/orlando/centerwell-the-villages.html?utm_medium=businesslistings&utm_campaign=gmb_orl_online-listings_en_digital_evergreen)

[Manza]

And just why do you think you are entitled to that information? This is strictly between CMS and TVH, YOU are not involved.
We will all be informed when arrests are made. Otherwise, the coverup will continue.

[BrianL99]

Regular Medicare does not require pre-authorization for anything.

Regular Medicare with an AARP supplement is the way to go long-term. .


You need to check your facts.

Many things need pre-authorization with Medicare.

AARP is not an insurer. Their Medicare Plans are UnitedHealthcare, who license the AARP name.

[Rainger99]

So Medicare was overpaid by TVH millions of dollars? Medicare used those million of dollars for a span of time? Now, Medicare wants to penalize TVH because they got more money than they should have? Don't understand the penalty for getting & using more money...

I think you have it backwards. Medicare was over billed by the Villages. For example, if the payment for the procedure is $100, the Villages was billing more than $100. So Medicare was paying more than the correct amount. Medicare wants the money back.

[NoMo50]

It is somewhat humorous that so many people posting here think they know exactly what happened within TVH, when, in fact, none of them know. In spite of a carefully worded article printed in The Villages Daily Sun on July 4th, this announcement is a big deal, given the amount of money involved, and the possible ramifications.

It has been reported that TVH has a debt to the Federal government in the hundreds of millions of dollars, plus interest and penalties. The interesting thing about that, though, is you typically don't hear about the government assessing penalties unless there is fraud or egregious behavior involved. Think about your taxes. If you make a mistake, and underpay your Federal taxes, you will be assessed the amount owed plus interest. Penalties generally come into play when fraud or some other purposeful behavior is alleged.

Supposedly, TVH reported the overpayments in December 2024. What is not mentioned is how these overpayments came to light. Was it due to an external audit, where reporting to the Federal government was imminent? Were the discrepancies discovered internally by TVH employees? It seems almost inconceivable that a simple "billing discrepancy" would go unnoticed for years, while generating massive payments into the system.

The timing of the bankruptcy filing is also curious. The filing apparently occurred on July 3rd, on the heels of an announcement by the Federal Department of Justice, on June 30th, of indictments in the largest health care fraud case in history. Nothing suggests, at least at this time, that TVH was involved in the federal case...but the timing is still curious.

Again, this is big news in The Villages that will bear watching moving forward. There could be implications for an awful lot of people living here, and not just those currently getting the medical care from TVH.

[kingofbeer]

With owing millions from the Medicare over billing it may be the only option. Really want them to be successful as we need all of the medical options we can get here. It was interesting the Sun article indicated that all insurance will be accepted during the realignment hope that is true. Beautiful facilities were limited for Medicare patients to only Medicare advantage, hope that changes. May increase their success.
I do not know how the Villages Health could have overbilled. All patients are enrolled in select Medicare Advantage plans. Here is an example of a doctor visit:
$249.00 Billed
$123.95 Allowed
$121.48 Plan Paid
So, the Villages Health should be allowed to collect $2.47 from Medicare. If they collected more than $2.47, then there would be an o overpayment. I think any overpayments would be a fraud or just stupidity from the Villages Health.

[OrangeBlossomBaby]

At this point, I don’t think we can reach any conclusion as to whether it was a coding error or whether it is fraud.

All we have is a conclusory statement from TVH. I know that corporations “always” tell the truth but I would like to hear more details before I make any final decision as to what happened.

Intrawebz armchair lawyering is pretty silly.

1. It's not up to you to "decide." The decision was already made.
2. Medicare has already acknowledged that it was an error, not fraud.
3. You aren't owed any further details, but if you REALLY care, you'll fill out the appropriate FOIA forms and submit them to the state and federal government, and wait the expect 6-months-to-never for a response.

[kingofbeer]

Intrawebz armchair lawyering is pretty silly.

1. It's not up to you to "decide." The decision was already made.
2. Medicare has already acknowledged that it was an error, not fraud.
3. You aren't owed any further details, but if you REALLY care, you'll fill out the appropriate FOIA forms and submit them to the state and federal government, and wait the expect 6-months-to-never for a response.
Where is the document that says it was not Medicare fraud?

[OrangeBlossomBaby]

Computer error, and never flagged? What’s the basis for your comment? I went round and round with you relative to this back in January when I said that there was probably a DOJ investigation which you said wasn’t the case.

It wasn't just a "computer error." Yes I used that term, yes you're quoting me. I was simplifying it so as to not have to type paragraph upon paragraph of hypotheticals to explain a complicated process that could result in a simple error, that would further result in disastrous outcomes. It was a mis-coding. The computer didn't make a mistake. The input was incorrect. If you've ever worked on a medical billing floor you'd understand how this mistake might be made.

An example: a "yearly checkup" might have several diagnostic codes attached to it. It might be C400, C407, C802, C803, R931 (I'm making those up, they might actually be code for something but I'm pulling them out of my head, not from a coding list). The coder inputs the wrong one. Maybe the routine annual physical is supposed to be C803. But the billing department has been entering it as C802, which might be "specialty yearly checkup for patients with early onset dementia, requiring extra stuff that costs more". Because a yearly checkup - no matter what the code is - doesn't cost the patient anything, the patient will never see a bill for it. But Medicare might see a specialty diagnosis that incurs a surcharge of $270 in addition to the $130 they might be paying for a routine annual physical, which has a different code. They'll pay it, because it's a yearly thing. It won't flag, unless it's noticed that it isn't happening yearly. It also isn't likely to flag when it's a "early onset dementia that costs more" yearly exam, when it's a medical group catering to seniors, since early onset dementia isn't all that uncommon for a group that caters to seniors.

Whoever has been inputting the yearly checkups, has been putting in the wrong ones, over and over again. Medicare's been paying on it, because it really IS a yearly checkup - even though it's the wrong code out of the list of codes for yearly checkups.

It's a mistake. The person entering the code didn't mistype, they miscoded. The Medicare system's accounts payable department never flagged it, because they had no reason to flag it. So it just kept paying out too much.

Until someone in the billing department at TVH brought the incorrect code to their boss's attention.

That's all that happened (though I don't know which code(s) were mis-coded, I was using a hypothetical above). It caused a HUGE financial disaster, but the error itself was simple, and not nefarious.

[OrangeBlossomBaby]

This is the site for Centerwell Health that is closest to The Villages. It is about 6 miles from UF Health Spanish Plains (The Villages Hospital). You may get a feel for what to expect if the sale is approved.

The Villages, FL | CenterWell Senior Primary Care (https://www.centerwellprimarycare.com/en/florida/orlando/centerwell-the-villages.html?utm_medium=businesslistings&utm_campaign=gmb_orl_online-listings_en_digital_evergreen)

It's not 6 miles from the hospital. It's on the same campus, they share a parking lot. It's behind the Sharon Morse Medical Center.

[justjim]

TVH caught the mistakes and reported it to Medicare. The miscoding was not intentional - if it was, then yeah it'd be fraud, and TVH would be under criminal investigation. Medicare acknowledged that this was a mistake. A HUGE mistake, but a mistake nonetheless.

TVH auditors likely caught it. Their lawyers advised them to file bankruptcy and sell. And that is exactly what they did. People go to prison for a lot less but money to have an army of lawyers can certainly lesson the impact and claim just a honest mistake. It’s the golden rule. Those that have the gold rule. Having “political power” doesn’t hurt either. Occasionally a bone with little meat on it is thrown to us in the middle class. That keeps most of us reasonably happy. Fore.

[Rainger99]

2. Medicare has already acknowledged that it was an error, not fraud.

Where did they acknowledge that? Do you have a statement or press release from Medicare?

[drducat]

Take another whiff, it was a computer error that went unnoticed for a long time. Once TVH noticed it they immediately notified CMS. NO FRAUD

The DOJ is involved and looking into HCC up billing due to the amount of overpayment...the amount is too high to be an error..at any rate TVH is going to be on the hook to CMS for the $361 million after Humana owned co takes over...of course the amount is negotiable however the gov is being very aggressive.

[BrianL99]

TVH auditors likely caught it. Their lawyers advised them to file bankruptcy and sell.


So you think it's only coincidence that the "computer glitch" was found, after TV Health started merger talks with CenterWell?

Why do you suppose TVH Auditors missed it every year, for the 1st 4 years it was going on?

[OrangeBlossomBaby]

Where is the document that says it was not Medicare fraud?

Heck if I know, it was in the news at the end of last year, and patients got the e-mail from TVH. I'm a patient, I got the e-mail. I read it, and deleted it, just like I do with any other e-mails that I don't need to save for any reason.

Seriously - this is not news. TVH reported the error, it was acknowledged. The sale of TVH is the "news" part of this whole thing.

[Blueblaze]

It sounds like good news to me. I was going to try Centerwell this year, anyway. Maybe they'll finally take my Humana Advantage PPO and hire some doctors.

It's always been a crime to see those beautiful facilities go to waste, just because The Villages had some corrupt deal with United. We tried it the first couple of years after we moved here and got tired of being sent to some glorified nurse every time. It took 3 months to schedule a visit with your actual doctor. When we left, they even refused to release our medical records.

What concerns me is the possibility of the government going after The Villages for that money, and bankrupting the development company. We might be about to discover how much of that "free golf", "free entertainment", and everything else we supposedly pay for with our CDD fees, is actually subsidized by new houses and phony medicare bills.

[Moderator]

Please stay on Topic - Villages Health Chapter 11.

[tophcfa]

- TVH (The Villages health) problems began in late 2024, when Medicare auditors flagged $250 million in billing overpayments, a sum that could balloon with penalties
- Centerwell (CW) was negotiating to purchase TVH (The Village’s Health) last fall when they discovered the billing and coding issues and backed out, about the same time TVH reportedly self reported the issue
- Filing for chapter 11 allowed TVH to restructure its debt while continuing its operations, but it liabilities remain a ticking time bomb
- The deal TVH reached with CW is designed to allow CW to acquire the assets, but sidestep the TVH’s looming liabilities. CW has entered into a “ stalking horse” purchase agreement to purchase TVH assets at a minimum floor price, but the sale will ultimately go through an auction process. The purchase agreement gives CW an advantage over other bidders as they have the option to match other bidders price and are now privy to information to do their due diligence. The court will oversee the sale process
- It’s not entirely clear whether Chapter 11 protects TVH from its Medicare related government liabilities, chapter 11 does not protect from TAXES owed to the government
- An ultimate sale to CW is by no means a done deal at this point, they have simply entered into a stalking horse asset purchase agreement
- Court fillings indicate Villages Health Holding Company has a 66.3% Equity interest in TVH.
- Stay tuned, this will most definitely get more interesting as facts are leaked out or become public information

[Caymus]

- TVH (The Villages health) problems began in late 2024, when Medicare auditors flagged $250 million in billing overpayments, a sum that could balloon with penalties
- Centerwell (CW) was negotiating to purchase TVH (The Village’s Health) last fall when they discovered the billing and coding issues and backed out, about the same time TVH reportedly self reported the issue
- Filing for chapter 11 allowed TVH to restructure its debt while continuing its operations, but it liabilities remain a ticking time bomb
- The deal TVH reached with CW is designed to allow CW to acquire the assets, but sidestep the TVH’s looming liabilities. CW has entered into a “ stalking horse” purchase agreement to purchase TVH assets at a minimum floor price, but the sale will ultimately go through an auction process. The purchase agreement gives CW an advantage over other bidders as they have the option to match other bidders price and are now privy to information to do their due diligence. The court will oversee the sale process
- It’s not entirely clear whether Chapter 11 protects TVH from its Medicare related government liabilities, chapter 11 does not protect from TAXES owed to the government
- An ultimate sale to CW is by no means a done deal at this point, they have simply entered into a stalking horse asset purchase agreement
- Court fillings indicate Villages Health Holding Company has a 66.3% Equity interest in TVH.
- Stay tuned, this will most definitely get more interesting as facts are leaked out or become public information

So, when it's all over who will be financially impacted? Whoever owns Village Health holding company? Bond Holders (if any)? The money lenders? US Government?

[Normal]

This is the same group who asked me 3 questions and called it a “WellnessCheck”. In turn they billed Medicare 160 bucks. I hope they get fried. Follow the money and bust them all!

[bmcgowan13]

They scammed the system (over billing Medicare HUNDREDS OF MILLIONS). This is the fraud and abuse that the current administration is trying to fix. Know that they have or will also over bill patients (you and me) also without even a pause to consider ethics.


Unfortunately, TVH is not alone. Remember Columbia Health care from 2003? Remember, TVH SELF-REPORTED this case unlike Columbia which was the result of whistleblowers exposing corrupt management...and nobody went to jail from Columbia.

Certainly TVH deserves a little credit here.

#386: 06-26-03 LARGEST HEALTH CARE FRAUD CASE IN U.S. HISTORY SETTLED HCA INVESTIGATION NETS RECORD TOTAL OF $1.7 BILLION (https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386.htm)

[Plinker]

This is the same group who asked me 3 questions and called it a “WellnessCheck”. In turn they billed Medicare 160 bucks. I hope they get fried. Follow the money and bust them all!

Agree. I believe they up-coded to the tune of hundreds of millions of dollars. Up-coding is very common and often deliberate. How much of that money went to management as salary and bonuses instead of patient care? You live in a pollyannish world if you think the bankruptcy, overcharging and sale is all just a coincidence.
Blaming this on a computer error is ridiculous. Without these hundreds of millions of dollars in overcharges, would TVH not gone under long before now?

[Keninches]

We went with VH for a brief period when they first started. Never saw the doctor. When we received a letter stating “go with a Medicare Advantage or get thrown out,”. We left, no way were we changing to an Advantage Plan. Medicare Advantage is Not an Advantage.

[golfing eagles]

The DOJ is involved and looking into HCC up billing due to the amount of overpayment...the amount is too high to be an error..at any rate TVH is going to be on the hook to CMS for the $361 million after Humana owned co takes over...of course the amount is negotiable however the gov is being very aggressive.

Investigating and being guilty are 2 different things. And where was it stated that the DOJ was investigating anyway????

[golfing eagles]

Someone in the medical business would know better, but I believe the "coding" and billing process is completely different for Advantage insurers, vs Supplemental insurers.

Again, just an educated guess ... with a Supplemental Plan, the consumer/patient is more involved in the process, up and through billing. Depending on the specifics of the supposed "computer error", it's likely that it would have been caught sooner with a Supplemental plan ... the billing is more transparent.

Actually, you are more correct than you might think. TVH is paid on a diagnostic complexity per patient per month basis, different from straight Medicare.

[dgoodman]

Interesting, but not surprising. The fact that they only accepted certain Advantage plans, and no Medigap plans, for primary care immediately raised the hair on the back of my neck that something fishy was going on. As far as I’m aware, they were the only large health care operation in the country serving a predominantly senior citizen population that wouldn’t accept traditional Medicare. My intuitive suspicions aren’t always correct, but apparently it was this time.

It was only for primary care physicians that they only took Medicare Advantage, specialty care physicians accepted standard Medicare Medigap plans.

[golfing eagles]

Okay, so this is may be true.
What a shame they didn't have enough business acumen to have an annual audit by certified auditor.
Even small business operations know to check the books. What am I missing Doc?

OK, I'll try to explain what happened (and realize that 99% of previous posts are just speculative BS):

Let's give an example: A patient taking aspirin after previous vascular surgery for say carotid occlusion has easy bruising. It gets coded as "acquired platelet dysfunction", which is exactly what it is. Or is it? Depends on interpretation. So the outside auditors for TVH tell them it is absolutely correct to use that code (Yes, they have continuous outside auditing). Then they get into negotiations with Humana, and Humana says that's wrong, you can't use that code in this instance. So TVH self-reports the discrepancy to CMS and this whole thing begins. There's more to it that I'm not at liberty to discuss, but there was NO INTENT TO DEFRAUD.

[biker1]

My wife, who knows her way around medical insurance after practicing for 40 years, alerted me about an insurance issue. She had gone in for a normal blood draw before an annual wellness visit and they wanted to do a vitals check on her. She declined since she suspected they would code it as an office visit. A month later, I went in for a normal blood draw, and I told them they could skip any vitals check. They said they weren’t doing that any more. Neither one us us has any health issues. Hmmm …

This is the same group who asked me 3 questions and called it a “WellnessCheck”. In turn they billed Medicare 160 bucks. I hope they get fried. Follow the money and bust them all!

[Bjeanj]

I am still amazed by those who automatically believe the worst in any situation, and nothing will convince them they are wrong.

[BrianL99]

Actually, you are more correct than you might think. TVH is paid on a diagnostic complexity per patient per month basis, different from straight Medicare.



A patient taking aspirin after previous vascular surgery for say carotid occlusion has easy bruising. It gets coded as "acquired platelet dysfunction", which is exactly what it is. Or is it? Depends on interpretation. So the outside auditors for TVH tell them it is absolutely correct to use that code (Yes, they have continuous outside auditing). Then they get into negotiations with Humana, and Humana says that's wrong, you can't use that code in this instance.


If there's $360M in over billing, it seems the hammer needs to come down on someone, but it's not clear from your characterization, whether it should be TVH or Humana (I thought TVH was affiliated with United Healthcare?).

So either the local office (TVH) "coded" too low on the complexity scale and their Insurance company made them raise the "complexity score" (which would seem to indicate shared responsibility for the errors) or ...

The local office coded too high and the Insurance company insisted they lower the "complexity score". (which would mean they weren't getting paid (or billing) enough money, therefore no "fraud"?)

I'm sure I'm missing something in this equation, but I'm not sure what it is.

[Velvet]

It wasn't just a "computer error." Yes I used that term, yes you're quoting me. I was simplifying it so as to not have to type paragraph upon paragraph of hypotheticals to explain a complicated process that could result in a simple error, that would further result in disastrous outcomes. It was a mis-coding. The computer didn't make a mistake. The input was incorrect. If you've ever worked on a medical billing floor you'd understand how this mistake might be made.

An example: a "yearly checkup" might have several diagnostic codes attached to it. It might be C400, C407, C802, C803, R931 (I'm making those up, they might actually be code for something but I'm pulling them out of my head, not from a coding list). The coder inputs the wrong one. Maybe the routine annual physical is supposed to be C803. But the billing department has been entering it as C802, which might be "specialty yearly checkup for patients with early onset dementia, requiring extra stuff that costs more". Because a yearly checkup - no matter what the code is - doesn't cost the patient anything, the patient will never see a bill for it. But Medicare might see a specialty diagnosis that incurs a surcharge of $270 in addition to the $130 they might be paying for a routine annual physical, which has a different code. They'll pay it, because it's a yearly thing. It won't flag, unless it's noticed that it isn't happening yearly. It also isn't likely to flag when it's a "early onset dementia that costs more" yearly exam, when it's a medical group catering to seniors, since early onset dementia isn't all that uncommon for a group that caters to seniors.

Whoever has been inputting the yearly checkups, has been putting in the wrong ones, over and over again. Medicare's been paying on it, because it really IS a yearly checkup - even though it's the wrong code out of the list of codes for yearly checkups.

It's a mistake. The person entering the code didn't mistype, they miscoded. The Medicare system's accounts payable department never flagged it, because they had no reason to flag it. So it just kept paying out too much.

Until someone in the billing department at TVH brought the incorrect code to their boss's attention.

That's all that happened (though I don't know which code(s) were mis-coded, I was using a hypothetical above). It caused a HUGE financial disaster, but the error itself was simple, and not nefarious.

To take your example of miscoding, say $270 vs $130 for the type of visit. For one year of over billing $90,000,000 they would have had to miscode 642,857 times in order to make such a difference. So each and every person in TV would have to have this “annual checkup” 4 times a year - every year for 4 years - to come up with the magnitude of the error.

Hmmm.

[Aloha]

I currently have Centerwell as my Healthcare provider. I am not pleased by the competence level of some of the office staff. As they take over in the various locations, they need to ensure that a competent staff is in place that will supply adequate support for the Senior patients. Please be vigilant as the transfer process occurs. I suspect there will be serious issues for some.

[golfing eagles]

If there's $360M in over billing, it seems the hammer needs to come down on someone, but it's not clear from your characterization, whether it should be TVH or Humana (I thought TVH was affiliated with United Healthcare?).

So either the local office (TVH) "coded" too low on the complexity scale and their Insurance company made them raise the "complexity score" (which would seem to indicate shared responsibility for the errors) or ...

The local office coded too high and the Insurance company insisted they lower the "complexity score". (which would mean they weren't getting paid (or billing) enough money, therefore no "fraud"?)

I'm sure I'm missing something in this equation, but I'm not sure what it is.

I'm not sure what is meant by "local office", but I think the people who missed the boat most are those that created this ridiculous system of diagnostic codes and procedural codes that no one really understands and are either intentionally or accidentally vague at best.

This "coding crisis" began back around 1987 with the advent of "DRG's" (Diagnostically Related Groups) to determine hospital reimbursement, as well as LOS (Length of Stay) parameters and outliers. A new category of employees was created, "the coders". Reimbursement became dependent upon how many diagnoses were listed, but get this, also the order in which they were submitted. Billing departments all over the country told physicians to just list every diagnosis a patient had, whether relevant or not to their stay, and "the coders" would put them in the most beneficial for reimbursement order, which was created by the brain children at CMS in the first place.

Over the years, this grew and grew, and created more regulators (nitpickers) as the coding became more complex and more vague. This created another layer of complexity (and employment), the "outside auditors". Every medical practice had a way of auditing their coding. Small practices would generally conduct internal audits by having a colleague review their encounter note and coding. Large practices and hospitals would hire these "outside auditors" to do the same. This was necessary because it was better to find your own problems/mistakes and self-report than to have CMS find it first, penalties were less severe. TVH is a very large practice and has outside auditors.

CPT coding is almost as complex as ICDM-10 coding in some ways. For traditional fee for service billing, the difference between a 99213 and 99214 is about $40, which can be make or break in a small practice with large overhead. But your documentation better fit the code submitted (Note: I said "documentation. Not how much time you devoted to the encounter, not how much judgement and skill was required, just what you wrote in your note. I'm sure many of you have gone to a physician that spent more time typing into his laptop than engaging you, the patient---this government/insurance industry/lawyer concept of "if you didn't write it down it didn't happen" has pervaded the medico-legal industry and to a certain degree paralyzed meaningful patient encounters in favor of "documenting. What you write is now more important than what you did. Sad.)

The difference between 99213 and 99214 requires an "expanded problem focused history" as opposed to a "problem focused history", 2 items from past history, family history or social history as opposed to none, and at least 2 items in 6 categories of the review of systems. There must be at least 6 systems physically examined, as opposed to one, with 2 items from each of those documented. And then you need a "moderate" level of complexity, which is vaguely defined but has a point system for reviewing lab/x rays/procedures/etc. and best of all an ill-defined "complexity of medical decision making". So from the 3 main categories---history, physical, and complexity---2/3 are necessary for a 99214 (established patient) and all three for 99204 (new patient). I hope this gives the layperson and small idea of just what goes into coding just a simple visit for say HTN and elevated cholesterol, and the pitfalls/potential for errors that ensue. Rest assured, CMS is constantly watching for so called "over coding". They periodically require you to submit 25 notes for review and will gleefully penalize even one mistake. And that's just the CPT billing coding; the diagnostic coding is even more complex. So that's traditional Medicare that I am most familiar with, TVH is reimbursed based upon the more complex billing coding structure, which is also vague and subject to interpretation.

Diagnostic coding is defined in the ICDM-10 handbook of a zillion codes---7 digits with 2 digit modifiers for a total of 9. I defy anyone, even a professional coder, to state they understand the whole system. Here's an example of a real code that I saw a while back:
"Struck by bird, goose, flying, in right flank, renal capsule perforated, minimal blood loss, not requiring dialysis". That must come up about once every 100 million years. But I'll give a more realistic example---"acquired platelet dysfunction". Everybody on aspirin technically has that diagnosis---subject to interpretation. This may have been submitted to an outside auditor who said it's fine. Then, maybe, in negotiation for a sale it came up again and wasn't considered fine. So they is no choice but to self report and now the chips are going to fall where they may. But anyone who jumps on the intentional fraud bandwagon has no idea of what they are talking about. None whatsoever.

[Accidental1]

I'm not sure what is meant by "local office", but I think the people who missed the boat most are those that created this ridiculous system of diagnostic codes and procedural codes that no one really understands and are either intentionally or accidentally vague at best.

This "coding crisis" began back around 1987 with the advent of "DRG's" (Diagnostically Related Groups) to determine hospital reimbursement, as well as LOS (Length of Stay) parameters and outliers. A new category of employees was created, "the coders". Reimbursement became dependent upon how many diagnoses were listed, but get this, also the order in which they were submitted. Billing departments all over the country told physicians to just list every diagnosis a patient had, whether relevant or not to their stay, and "the coders" would put them in the most beneficial for reimbursement order, which was created by the brain children at CMS in the first place.

Over the years, this grew and grew, and created more regulators (nitpickers) as the coding became more complex and more vague. This created another layer of complexity (and employment), the "outside auditors". Every medical practice had a way of auditing their coding. Small practices would generally conduct internal audits by having a colleague review their encounter note and coding. Large practices and hospitals would hire these "outside auditors" to do the same. This was necessary because it was better to find your own problems/mistakes and self-report than to have CMS find it first, penalties were less severe. TVH is a very large practice and has outside auditors.

CPT coding is almost as complex as ICDM-10 coding in some ways. For traditional fee for service billing, the difference between a 99213 and 99214 is about $40, which can be make or break in a small practice with large overhead. But your documentation better fit the code submitted (Note: I said "documentation. Not how much time you devoted to the encounter, not how much judgement and skill was required, just what you wrote in your note. I'm sure many of you have gone to a physician that spent more time typing into his laptop than engaging you, the patient---this government/insurance industry/lawyer concept of "if you didn't write it down it didn't happen" has pervaded the medico-legal industry and to a certain degree paralyzed meaningful patient encounters in favor of "documenting. What you write is now more important than what you did. Sad.)

The difference between 99213 and 99214 requires an "expanded problem focused history" as opposed to a "problem focused history", 2 items from past history, family history or social history as opposed to none, and at least 2 items in 6 categories of the review of systems. There must be at least 6 systems physically examined, as opposed to one, with 2 items from each of those documented. And then you need a "moderate" level of complexity, which is vaguely defined but has a point system for reviewing lab/x rays/procedures/etc. and best of all an ill-defined "complexity of medical decision making". So from the 3 main categories---history, physical, and complexity---2/3 are necessary for a 99214 (established patient) and all three for 99204 (new patient). I hope this gives the layperson and small idea of just what goes into coding just a simple visit for say HTN and elevated cholesterol, and the pitfalls/potential for errors that ensue. Rest assured, CMS is constantly watching for so called "over coding". They periodically require you to submit 25 notes for review and will gleefully penalize even one mistake. And that's just the CPT billing coding; the diagnostic coding is even more complex. So that's traditional Medicare that I am most familiar with, TVH is reimbursed based upon the more complex billing coding structure, which is also vague and subject to interpretation.

Diagnostic coding is defined in the ICDM-10 handbook of a zillion codes---7 digits with 2 digit modifiers for a total of 9. I defy anyone, even a professional coder, to state they understand the whole system. Here's an example of a real code that I saw a while back:
"Struck by bird, goose, flying, in right flank, renal capsule perforated, minimal blood loss, not requiring dialysis". That must come up about once every 100 million years. But I'll give a more realistic example---"acquired platelet dysfunction". Everybody on aspirin technically has that diagnosis---subject to interpretation. This may have been submitted to an outside auditor who said it's fine. Then, maybe, in negotiation for a sale it came up again and wasn't considered fine. So they is no choice but to self report and now the chips are going to fall where they may. But anyone who jumps on the intentional fraud bandwagon has no idea of what they are talking about. None whatsoever.

Is this complex coding system the same for Advantage and Traditional Medicare patients?

[HiHoSteveO]

Investigating and being guilty are 2 different things. And where was it stated that the DOJ was investigating anyway????

YouTube video of DOJ press conference link below posted a few days ago.
https://www.youtube.com/watch?v=dFtO2fL97gY

[RoseyRed]

Yes I see your point. I do wonder how the audit process did not catch the coding issues mentioned much sooner. Where did all the "extra" money go? Why did TVH not look into why there was so much more money coming in those 4 yrs?

OK, I'll try to explain what happened (and realize that 99% of previous posts are just speculative BS):

Let's give an example: A patient taking aspirin after previous vascular surgery for say carotid occlusion has easy bruising. It gets coded as "acquired platelet dysfunction", which is exactly what it is. Or is it? Depends on interpretation. So the outside auditors for TVH tell them it is absolutely correct to use that code (Yes, they have continuous outside auditing). Then they get into negotiations with Humana, and Humana says that's wrong, you can't use that code in this instance. So TVH self-reports the discrepancy to CMS and this whole thing begins. There's more to it that I'm not at liberty to discuss, but there was NO INTENT TO DEFRAUD.

[golfing eagles]

Is this complex coding system the same for Advantage and Traditional Medicare patients?

Yes. They all come from ICDM 10

[Rainger99]

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) includes over 70,000 diagnosis codes and the CPT (Current Procedural Terminology) code set, maintained by the American Medical Association (AMA), contains over 10,000 procedure codes.

It seems complicated. I would think AI could do it faster and more accurately than a team of people.

[golfing eagles]

Yes I see your point. I do wonder how the audit process did not catch the coding issues mentioned much sooner. Where did all the "extra" money go? Why did TVH not look into why there was so much more money coming in those 4 yrs?

Because it wasn’t “extra money”. It was just the expected reimbursement from the submitted billing. And (not that I know anything), the external auditors agreed. There was no discrepancy (not that I know anything) until negotiations with Humana uncovered what Humana thought was wrong coding. When this happens, it is best to self report to CMS, and guess which side the federal investigation would fall on??? No need to guess, we all know the answer

[Altavia]

Because it wasn’t “extra money”. It was just the expected reimbursement from the submitted billing. And (not that I know anything), the external auditors agreed. There was no discrepancy (not that I know anything) until negotiations with Humana uncovered what Humana thought was wrong coding. When this happens, it is best to self report to CMS, and guess which side the federal investigation would fall on??? No need to guess, we all know the answer

What's the odds Humana would find similar discrepancies with any other practice?

[golfing eagles]

All I can say is that if jumping to conclusions were an Olympic sport, this thread would hold the world record

[golfing eagles]

What's the odds Humana would find similar discrepancies with any other practice?

Humana, a random outside auditor, or CMS can find similar discrepancies with EVERY practice. The reason is that the definitions of many diagnoses are extremely vague. And if you ask CMS what they want you to code in a given circumstance or how to do it, they WILL NOT GIVE YOU AN ANSWER. But don't ever actually ask them, because they will flag you for increased surveillance.

[CoachKandSportsguy]

Because it wasn’t “extra money”. It was just the expected reimbursement from the submitted billing. And (not that I know anything), the external auditors agreed. There was no discrepancy (not that I know anything) until negotiations with Humana uncovered what Humana thought was wrong coding. When this happens, it is best to self report to CMS, and guess which side the federal investigation would fall on??? No need to guess, we all know the answer

All makes sense, until you realize that there are different levels of auditors. Yes, how do I know? because an excellent corporate accounting friend was witness to all the TYCO accounting and GE accounting which was illegal, TYCO CFO went to prison, GE was finally caught, and the auditors signed off. Same friend also worked at a private accounting firm where the owners would forge documents if that is what the customer wanted. I personally worked with some E&Y auditors, who I had to report to my superiors as breaking the law., putting the company at risk. Auditors go mad at me. .

Enron auditors? where were they? Arthrr Anderson, where are they now?

All auditors are not the same, especially as the firms get smaller and are private. . .

[drducat]

Expected Revenue: Approximately $770 million annually for 55,000 Medicare patients, based on an average of $14,000 per beneficiary.Expected Profit (Loss): Likely a loss of $157.7 million annually, assuming Medicare reimburses 83% of costs. In an optimistic scenario with cost optimization, a small positive margin (e.g., $38.5 million) is possible but unlikely without commercial payer revenue or special programs like 340B. Tuff to make any money without some fancy coding or diagnosis. Inconclusive risk assessment is at play here.

[Cdj1040]

What’s your thoughts on Villages Health filing chapter 11

Glad we opted for United Health Care Medicare Advantage thru AARP.
It covers nationwide and I have used it up north with no problems. Many providers to choose from. If you travel at all stick to insurance with out of area coverage. I managed a medical office so right away after checking it out, we avoided Villages Health in spite of their lovely buildings and one stop medical care ideology. Better to shop providers, check their training, and choose your own wherever you happen to be.

[M2inOR]

Expected Revenue: Approximately $770 million annually for 55,000 Medicare patients, based on an average of $14,000 per beneficiary...

The above quote is worth paying attention to.

This is the amount the US government pays each year automatically for each Medicare Advantage patient member, over and above what is being billed.

This gives The Villages Health and other primary healthcare providers a fixed amount to support the operation. Before coming to the Villages, we had a Medicare Advantage plan with Kaiser Permanente in Oregon. We had Kaiser HMO for all our working years before retiring at 65 and enrolling in Medicare.

We liked the HMO very much, so taking the Medicare Advantage when we retired was an easy choice for us. Our experience with UHC and Medicare Advantage with TVH has been excellent, too.

I hope this gets resolved quickly. And I hope the uninformed speculation disappears when replaced by facts. I want TVH to continue to provide the excellent Healthcare my wife and I have received over the past 5 years.

[Marmaduke]

I am astounded that anyone could possibly believe this was an innocent computer error. I’ve got some swamp land to sell ya that surrounds Alligator Alcatraz if you honestly believe that. Hundreds of millions of dollars were over billed over years, and the $$$ disappeared and isn’t listed as assets in the bankruptcy filling. And then the error was suddenly discovered and self reported, REALLY? Or they knew they were about to get busted and tried to save face and keep from getting thrown in prison by concocting a far fetched story of presumed innocence? If they actual let an innocent computer glitch over bill, and accept 100’s of millions over several years, then they are guilty of gross negligence, incompetence, and lack of any reasonable internal controls. And what happened to all that money, did the computer error miraculously make it disappear? This doesn’t pass even the most lenient of sniff tests.
I Concur with You 100%, and I'm a very logical person who would give any company the benefit of the doubt.
This deserves deep Federal Investigation, and nothing less, I'm sorry to say.

[Joe C.]

Not worried one bit.

[Velvet]

In mathematics, a true mistake goes both ways. One would err as often towards less as towards more of the correct figure. My internet provider consistently “errs” in their favor only, which means they are not erring at all. The bill is never lower than what it should be, only higher. So no it is not a “mistake”. Adding any degree of complexity, would not change this probability.

[OrangeBlossomBaby]

To take your example of miscoding, say $270 vs $130 for the type of visit. For one year of over billing $90,000,000 they would have had to miscode 642,857 times in order to make such a difference. So each and every person in TV would have to have this “annual checkup” 4 times a year - every year for 4 years - to come up with the magnitude of the error.

Hmmm.

Hmmm indeed! So - maybe - just maybe - you should accept that I said this was all hypothetical, an example of what kind of error might be made, and not focus on the dollar amount because the dollar amount clearly doesn't apply in the situation.

Consider the POINT:

A set of codes can apply to similar procedures. A billing error isn't a dollar amount. It's a coded diagnoses, which has a base cost attached to it.

WHATEVER THAT COST MIGHT BE....

Someone put in the wrong code, which came with a higher base cost than the correct code.

The result was an overpayment with no red flags, because the procedure attached to the code was correct, therefore not causing any red flags to go up.

[Eg_cruz]

What’s your thoughts on Villages Health filing chapter 11
I know one of the doctors who started so I am not surprised
Bad management and greed

[Velvet]

Hmmm indeed! So - maybe - just maybe - you should accept that I said this was all hypothetical, an example of what kind of error might be made, and not focus on the dollar amount because the dollar amount clearly doesn't apply in the situation.

Consider the POINT:

A set of codes can apply to similar procedures. A billing error isn't a dollar amount. It's a coded diagnoses, which has a base cost attached to it.

WHATEVER THAT COST MIGHT BE....

Someone put in the wrong code, which came with a higher base cost than the correct code.

The result was an overpayment with no red flags, because the procedure attached to the code was correct, therefore not causing any red flags to go up.

In order to bill $90,000,000 over CONSISTENTLY over years, and never under, makes it unlikely to be an error, more like accepted practice. At least it would be in most circumstances.

[joshgun]

In Advantage plans the plan is paid a flat fee on a per person adjusted for those with more significant problems. If TVH requested and was paid $90 million a year than Medicare the taxpayers are stuck with loss. One thing to keep in mind is how can TVH continue under Centerwell with $90 million less each year? Expect premium increases.

[tophcfa]

In Advantage plans the plan is paid a flat fee on a per person adjusted for those with more significant problems. If TVH requested and was paid $90 million a year than Medicare the taxpayers are stuck with loss. One thing to keep in mind is how can TVH continue under Centerwell with $90 million less each year? Expect premium increases.

The obvious answer is by buying TVH assets at a fire sale valuation and either not taking on their liabilities or by taking on significantly restructured liabilities. With significantly lower overhead costs, they have a reasonable chance of turning a profit using coding that generates less revenue.

[OrangeBlossomBaby]

YouTube video of DOJ press conference link below posted a few days ago.
https://www.youtube.com/watch?v=dFtO2fL97gY

The Villages Health is not on that list of defendants. I just checked the .gov website. TVH is not being investigated by the DOJ, at least not in conjunction with this "Takedown" project.

[Justputt]

What’s your thoughts on Villages Health filing chapter 11

Too soon to tell. Self-reporting is a CYA in case there are real legal problems. We had a RAC audit by Medicare that challenged nearly every case we use IMRT treatments (even when the treatment was considered Standard of Care!), and they wanted to claw back all the money. We appealed and had the documentation to support our work because our Department Director was OCD about having documentation complete to justify every charge. We won ALL BUT ONE CASE, and the one we lost we should have won but Medicare argued we should have used a cheaper therapy that would have caused more side effects for the patient because the outcome would be the same. Until we know more about the predominant charges, it's hard to determine REAL errors or fraud.

[OrangeBlossomBaby]

In order to bill $90,000,000 over CONSISTENTLY over years, and never under, makes it unlikely to be an error, more like accepted practice. At least it would be in most circumstances.

The error, if you were to figure this out logically, would be - that the accepted practice was incorrect OR *became* incorrect with the new potential buyer's system of "doing things."

See golfing eagles's post for a detailed explanation on that.

In summary:

"Our practice has been coding "widget fixing and whatsit-testing" as W401 for the past 15 years. It bills out at $5000 per incident. Medicare only allows $3000 per incident, pays $2980 per incident, and the patient pays $20."

Then Humana shows up and says "hey maybe we'll buy you." TVH says "let's self-audit to see what this bad boy is worth."

And they discover "omg Humana uses code W407 and W294 for these two things, separately. And combined those codes can only be billed at $2000. Medicare will only allow $1500, and will only pay $1480, with a $20 co-pay from the patient."

Considering that most patients have to have widget fixing and whatsit-testing at least once per year, and they have 55,000 patients, and some of those patients have to have these tests twice and even three times a year - there's gonna be a WHOPPING discrepancy.

The patient never sees any change - they're still on the hook for a $20 co-pay, no matter which way it's coded.

[Altavia]

So at the end of the day, medical providers are being punished for not denying medical services an auditor on third review felt were unnecessary?

[Velvet]

How did you conclude that, exactly? I’d just like to follow your thinking. Are you saying that medical practitioners were advising care to patients that was not covered but they were billing for it anyways? I am not sure I understand you.

The health care system really could benefit from universal care at a reasonable level, so that one would not have to “game the system” to provide decent care (in my opinion).

[4litehous]

It wasn't fraud. It was a really huge, significant flaw that TVH discovered, and reported. They were being overpaid for quite awhile. At some point, someone found what the problem was and said "hey boss - this is totally not right." And the boss said "OMG holy crap" and reported it to Medicare, and told Medicare "hey youz guyz - you've been sending us too much money! How do we give it back to you?" And Medicare said "oh golly gee let's figure this out" and they did.

Unfortunately, imposed penalties for overpayment don't get absorbed by the people who were doing the overpayment (Medicare) but by the entity that receives it (TVH). So they're on the hook for the millions in the government's overpayments, AND for penalties. Which - they can't afford.

The government calls it fraud--Fraud was discovered....

[Altavia]

How did you conclude that, exactly? I’d just like to follow your thinking. Are you saying that medical practitioners were advising care to patients that was not covered but they were billing for it anyways? I am not sure I understand you.

...



Just the opposite, Humana auditors are retrospectively over ruling the original medical code, that was also approved by two lower level auditors?

How many complaints have we heard about needed medical care being denied by insurance providers?

[tophcfa]

In mathematics, a true mistake goes both ways. One would err as often towards less as towards more of the correct figure. My internet provider consistently “errs” in their favor only, which means they are not erring at all. The bill is never lower than what it should be, only higher. So no it is not a “mistake”. Adding any degree of complexity, would not change this probability.

As a firm believer in statistics, you’re speaking my language. Statistics, using large random sample sizes don’t lie. If all codes used by TVH were analyzed for under billing, accurate billing, and over billing, a bell shaped curve would indicate random billing errors and wouldn’t suggest fraud. If the curve was highly skewed toward overbilling, randomness (in this case intentional coding toward over billing) would most definitely come into question. I’m not saying this is what happened, but if I was investigating a health care provider for possible fraud, I would have some sharp young math wiz, with an advanced degree in data sciences, crunching these numbers. If I was running the health care providers business, I would have a similar math wiz write a multi factored optimization algorithm that figured out how to reverse engineer the coding system for billing, so that codes could always be used that maximize revenue while staying within constraints that would trigger regulators (CMS) up coding flags. Thinking about it, Golfing Eagles said the CMS keeps everything about the system extremely vague and subject to interpretation, most likely on purpose to make it extremely difficult to identify the constraints triggering flags, making it almost impossible to write a coding optimization model. I’m glad I wasn’t in that line of business.

[Velvet]

Just the opposite, Humana auditors are over ruling the original medical code, that was also approved by two lower level auditors?

How many complaints have we heard about needed medical care being denied by insurance providers?

Unfortunately, sometimes the need exceeds what can be paid for. Just a quick story; when I first started teaching I noticed the janitor worked with an oxygen tank. I asked him about it and he said, he can afford the oxygen only for another several months after which he will most likely die. I thought he was kidding. Nine months later he was gone. I asked around and they told me, he had passed away.

[Jerry8542]

I am missing something. With the Medicare Advantage Plan, I thought that Medicare paid a fixed amount to your insurance company to cover your medical expenses and that the insurance company and not Medicare was billed for your care. If that is the case, how did Medicare overpay The Villages Health?

[golfing eagles]

The error, if you were to figure this out logically, would be - that the accepted practice was incorrect OR *became* incorrect with the new potential buyer's system of "doing things."

See golfing eagles's post for a detailed explanation on that.

In summary:

"Our practice has been coding "widget fixing and whatsit-testing" as W401 for the past 15 years. It bills out at $5000 per incident. Medicare only allows $3000 per incident, pays $2980 per incident, and the patient pays $20."

Then Humana shows up and says "hey maybe we'll buy you." TVH says "let's self-audit to see what this bad boy is worth."

And they discover "omg Humana uses code W407 and W294 for these two things, separately. And combined those codes can only be billed at $2000. Medicare will only allow $1500, and will only pay $1480, with a $20 co-pay from the patient."

Considering that most patients have to have widget fixing and whatsit-testing at least once per year, and they have 55,000 patients, and some of those patients have to have these tests twice and even three times a year - there's gonna be a WHOPPING discrepancy.

The patient never sees any change - they're still on the hook for a $20 co-pay, no matter which way it's coded.

100% correct, and surprisingly close to what actually happened

[golfing eagles]

The government calls it fraud--Fraud was discovered....

And just where did the government state it was fraud???

[OrangeBlossomBaby]

The government calls it fraud--Fraud was discovered....

No, it wasn't. The DoJ isn't investigating The Villages Health for fraud. There has been no fraud found with regards to this coding error at The Villages Health.

No fraud was discovered. It was a coding error. The Villages Health DISCOVERED it, and reported it to the government department in charge of dealing with government-paid health insurance payments (in this case, Medicare Advantage, primarily), and that entity ACCEPTED The Villages Health's assessment that they were overpaid due to a coding error.

That is all. That's all that happened. You might want to blame the prior administration for allowing TVH to commit this massive fraud. You might want to vilify TVH for committing this massive fraud. You have permission to want these things. But no amount of wishing will make it actually true.

[golfing eagles]

Just the opposite, Humana auditors are retrospectively over ruling the original medical code, that was also approved by two lower level auditors?

How many complaints have we heard about needed medical care being denied by insurance providers?

Actually, just the original code and one "lower level" auditing company.

[OrangeBlossomBaby]

100% correct, and surprisingly close to what actually happened

Contrary to popular belief, I am possessed of critical thinking skills. While not having much "expertise" in a variety of subjects, I am an expert in "looking stuff up." You should try reading the ENTIRE Connecticut General Statutes some time. All thirteen volumes (not including the 3 index volumes). If you went to a Connecticut public library and checked the physical bookshelf, you'd discover it's well over 8,000 pages (not including the 3 volumes of indexes). It's an eye-opener. I only read it because I wanted to help a friend who needed legal advice about her boyfriend adopting her son, whose biological father was a homeless drug addict with no known location or contact information. But it was interesting enough that I ended up reading the whole damned thing.

Mom always said - education for its own sake is priceless.

[drducat]

CMS and DOJ Collaboration:
The DOJ’s takedown was supported by CMS, which prevented $4 billion in fraudulent payments and revoked billing privileges for 205 providers. CMS’s role in identifying TVH’s overpayments suggests that the agency is already involved, which could lead to a DOJ investigation if evidence of fraud (e.g., intentional misrepresentation or kickbacks) is found.
The DOJ’s Health Care Fraud Data Fusion Center, established in 2025, uses AI and advanced analytics to detect emerging fraud schemes, increasing the likelihood that large overpayments like TVH’s would be flagged for review.

[OrangeBlossomBaby]

CMS and DOJ Collaboration:
The DOJ’s takedown was supported by CMS, which prevented $4 billion in fraudulent payments and revoked billing privileges for 205 providers. CMS’s role in identifying TVH’s overpayments suggests that the agency is already involved, which could lead to a DOJ investigation if evidence of fraud (e.g., intentional misrepresentation or kickbacks) is found.
The DOJ’s Health Care Fraud Data Fusion Center, established in 2025, uses AI and advanced analytics to detect emerging fraud schemes, increasing the likelihood that large overpayments like TVH’s would be flagged for review.

TVH has NOT BEEN FLAGGED FOR REVIEW. I don't know how much clearer this can be stated.

The DoJ is not investigating TVH. This is an issue that was resolved LAST YEAR. It's old news, Medicare already knows about it, they already knew about it, because TVH told them about it.

The repayment of the overpayments had already been in progress before the current announcement of Humana buying TVH and TVH filing for Chapter 11.

[golfing eagles]

TVH has NOT BEEN FLAGGED FOR REVIEW. I don't know how much clearer this can be stated.

The DoJ is not investigating TVH. This is an issue that was resolved LAST YEAR. It's old news, Medicare already knows about it, they already knew about it, because TVH told them about it.

The repayment of the overpayments had already been in progress before the current announcement of Humana buying TVH and TVH filing for Chapter 11.

Do you get the impression that we are tilting at windmills here. This thread now has posters just making stuff up, like "DOJ investigation" where none exists. Now we have "could lead to a DOJ investigation". Heck, spitting on the sidewalk within 30 feet of a US Congressman could lead to a DOJ investigation