Villages Health where did all the money go?

[Snowbirdtobe]

The Villages has received over $361,000,000 in over payments from the FEDS.
The bankruptcy filings has the US taxpayers or Medicare listed as an unsecured creditor due 361 Million US $. Where is that money? That is $6500 per patient.
I noticed that the rent was paid to TV. The rent looks to be 1,135,000 per month, but no rent is forecast for October, Nov, or Dec in the pro-forma DIP budget.

[tophcfa]

- The Villages Health (TVH) ran a unique business model for a large health care provider serving predominately a senior community. Unlike just about ever other similar health care provider, TVH primary care operation has not accept traditional medicare, only specific Medicare Advantage plans.

- Upcoding, when more diagnoses than are actually present are reported to increase medicare payments, are very rare with traditional Medicare and are almost exclusively limited to home care. On the other hand, upcoding has been widely abused with Medicare Advantage plans because under MA plans, payments are made on a risk-adjusted basis meaning higher risk scores (based on reported diagnoses) lead to higher payments.

- Despite the fact that patients with traditional Medicare and supplemental plans are generally sicker and require more health care than Medicare Advantage plan holders, Medicare Advantage plans pay out, on average, 22% more per patient than those with traditional medicare.

- Without audited financial statements, including a detailed sources and uses of funds statement, it is impossible to figure out what happened to the $$$ referenced by the author of this thread. That being said, based on the bankruptcy filing information, the amount of reported assets relative to liabilities certainly indicates the money wasn't retained in THV surplus account.

- A Florida Bankruptcy Judge preliminarily approved a $39 million debtor-in-possession (known as DIP financing) plan for TVH. DIP financing is a last ditch effort to raise money, often when in bankruptcy proceedings, to stay in operation during restructuring. DIP lenders require extremely stringent terms to insure their capital is protected, such as hard collateral and being court selected to be the first to be paid within the debtors capital structure. Based on TVH's reported assets, there won't be much money left after paying off the DIP loan for either their other creditors and the money owed to Medicare.

- Below is a statement from Latham and Watkins, a firm hired to help CenterWell (Humana) in the acquisition of TVH Assets, while not taking on the Liabilities. One thing is for certain, CenterWell is diving into a hornets nest, as evident by the long list of attorneys with various areas of expertise, retained to guide them through this process. No one in their right mind would dive into a hornets nest without lots and lots of protection. One can only imagine how much money the health care provider will spend on attorneys fees, rather than providing health care.

The Villages Health (TVH), announced that it has entered into a "stalking horse" Asset Purchase Agreement with CenterWell Senior Primary Care, the nation's largest senior-focused value-based primary care provider. The agreement provides for CenterWell, the healthcare services business of Humana Inc., to acquire TVH's assets as a going concern, including eight primary care centers and two specialty care centers. A Court order approving the sale, following an auction process during which other parties may submit an offer to purchase TVH's assets, will be a condition of the transaction moving forward and closing.

Latham & Watkins LLP represents CenterWell in the transaction with a corporate deal team led by Washington, D.C. partner Brian Mangino and New York partner Amber Banks and New York counsel Richard Quay, with associates Alice Bradshaw, Lauren Stern, and Daniel Maggen. Advice was also provided on intellectual property matters by Washington, D.C. partner Morgan Brubaker, with associate Tyra Richmond; on healthcare regulatory matters by Washington, D.C. partners Jason Caron and Joseph Hudzik, Chicago partner Terra Reynolds, and Washington, D.C. counsel Nicole Liffrig Molife, with associates Chad Leiper, Megan Lich, Margaret Rote, and Danielle Scheer; on data privacy matters by Bay Area partner Heather Deixler, with associates Kathryn Parsons-Reponte and Priyanka Krishnamurthy Crissman; on insurance matters by Century City partner Kirsten Jackson and New York counsel Alexander Traum; on tax matters by Washington, D.C. partner Andrea Ramezan-Jackson, with associate Nolon Blaylock; on benefits matters by Washington, D.C. partner David Della Rocca and Washington, D.C. counsel Laura Szarmach, with associate Rebecca Fishbein; on labor matters by New York counsel Sandra Benjamin, with associate Jenny Bobbitt; on real estate matters by New York partner Dara Denberg and New York counsel Shira Bressler, with associate Sarah Jeon; on finance matters by New York partner Kendra Kocovsky, with associate Benedict Bussmann; on environmental matters by New York counsel David Langer, with associate Tal Carmeli; and on restructuring matters by Washington, D.C./New York partner Andrew Sorkin and Chicago partner Caroline Reckler, with associates Isaac Ashworth and Brian Rosen.

- Just reporting some relevant facts here, what actually happened to the $$ is up to ones interoperation of the facts.

[Stu from NYC]

I am sure the Sun will be telling us the facts of the case.

If you believe that have a slightly used bridge to sell.:pepper2:

[spinner1001]

The Villages has received over $361,000,000 in over payments from the FEDS.
The bankruptcy filings has the US taxpayers or Medicare listed as an unsecured creditor due 361 Million US $. Where is that money? That is $6500 per patient.

Medical clinics serving mainly Medicare Advantage (MA) patients, such as TVH, generally operate very differently than traditional medical practices/ clinics. OP may be thinking about the business model of traditional medical practices. MA clinics operate differently and it’s complicated.

Perhaps much of the overpayment funds are with the Medicare Advantage insurance company(ies) that TVH works with under contract. The insurance company(ies) likely owes the US government (CMS) the overpayment. (CMS pays the MA insurer, and the insurer pays something to the MA clinic under terms of their contract.) But depending on the contract(s) between TVH and the insurance company(ies), the insurance companies may have the legal right to claw back overpayment funds from TVH for TVH’s mis-coding. Hence, the bankruptcy.

This is a business bankruptcy case so many details of TVH business dealings and contracts are not in the public domain and likely never will be. Speaking simply, business bankruptcy cases are about how much do the creditors and owners get from the bankrupt estate. In this case, the owners of TVH may get nothing for their equity stake after creditors, lawyers, etc get paid.

Don’t expect to see this bankruptcy case on a TV series. CMS overpayments are not rare. Each year, CMS makes billions of dollars of overpayments. And medical provider upcoding is also not rare.

CMS Takes Important Steps to Recover Overpayments from Medicare Advantage-2025-06-05 (https://www.crfb.org/blogs/cms-takes-important-steps-recover-overpayments-medicare-advantage)

Medicare Part C Improper Payment Measurement (IPM) | CMS (https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/medicare-part-c-ipm)

[Rainger99]

I don’t understand how the government is involved. If the Villages was mistakenly over billing by $90 million a year, wouldn’t they be over billing the Medicare Advantage plans - UHC, Humana, and BCBS?

From my research, Medicare pays a fixed amount each month to the private insurance company offering the plan to cover your medical expenses.

Medicare pays the insurance company a predetermined, fixed monthly amount (often referred to as a "capitation payment") for each enrollee, regardless of the actual medical services used. Apparently this is about $1,000 a month!!!

The insurance company, not Medicare, is responsible for managing and paying for your healthcare services. When you receive medical care, the provider (e.g., doctor, hospital) bills the insurance company administering your Medicare Advantage Plan, not Medicare directly.

In Original Medicare (Parts A and B), providers bill Medicare directly for covered services, and Medicare pays its share (typically 80% for Part B services), with you covering the rest (e.g., 20% coinsurance).

In contrast, Medicare Advantage shifts the financial risk to the private insurance company, which receives the fixed payment and manages all claims.

So if the insurance companies were over billed, how is Medicare involved?

[ROCKETMAN]

I’ve read all the posts so is there a simple answer to the question where did the $350 million go if that’s the right answer. They claimed assets of $50 to $100 million in the chapter 11.

[spinner1001]

In contrast, Medicare Advantage shifts the financial risk to the private insurance company, which receives the fixed payment and manages all claims.

That is only partially true. It is not a fixed payment in the Medicare Advantage system. CMS pays the MA insurance company a _risk-adjusted_ amount for each beneficiary. This means CMS’s MA payment to the insurance company is higher for sicker beneficiaries and lower for healthier beneficiaries. See the first link in my previous message. One aspect of this is a medical provider might upcode their services to make patients appear sicker so the CMS payment from the government is higher. Medicare Advantage is a complicated business model, not to mention the complex metrics for assessing the level of health for each MA beneficiary. It’s sort of like actuarial work and involves specialists and computer software.

[spinner1001]

I’ve read all the posts so is there a simple answer to the question where did the $350 million go if that’s the right answer. They claimed assets of $50 to $100 million in the chapter 11.

The information is not in the public domain and likely will never be. I guess much (but not all) of the overpayments was/is with the MA insurance company(ies). See my first post how TVH health might be legally responsible for reimbursement. Only insiders and the government know. Others don’t.

I understand that inquiring minds want to know details but they likely will never get information. Come to think of it, there might be an opportunity for a new TV series about all of this.

[CoachKandSportsguy]

makes you now realize why they only took Medicare Advantage plans, doesn't it?

[Rainger99]

This means CMS’s MA payment to the insurance company is higher for sicker beneficiaries and lower for healthier beneficiaries. See the first link in my previous message. One aspect of this is a medical provider might upcode their services to make patients appear sicker so the CMS payment from the government is higher.

So is that what happened here? The Medicare Advantage insurance companies were not over billed but Medicare overpaid on the capitation rate because TVH upcoded to make patients appear sicker than they actually were.

Even if you increased the capitation from $1,000 to $3,000, that would be $2,000 overpayment per patient so it would have to 45,000 patients to over bill $90,000,000.

[Aces4]

makes you now realize why they only took Medicare Advantage plans, doesn't it?

Yes and the old adage, "It was fun while it lasted", comes to mind. One wonders how much of this is going on all over the country.

[Snowbirdtobe]

Since the court filing lists the US Government as a debtor I’m going to assume that that insurance companies are not involved and the US government is owed the $. If the money was spent on perks and bonuses for staff and docs any company that takes over will have a hard time retaining anyone.

[Stu from NYC]

If TVH gets away with all these overpayments something is really rotten in Denmark as Shakespeare used to say.

[tophcfa]

Yes and the old adage, "It was fun while it lasted", comes to mind. One wonders how much of this is going on all over the country.

This kind of reminds me of the whole mortgage disaster, but on a different scale. In both cases, industry regulators created a moral hazard that provided the opportunity to make lots of money despite knowing the whole thing was a house of cards that would eventually come tumbling down. With subprime mortgages, the government wanted everyone to be able to own a home regardless of their financial capacity to actually repay the loan. Government guaranteed mortgages, coupled with significantly relaxed underwriting standards, created a moral hazard which allowed people to buy homes (or more expensive homes) than they could reasonably afford. Wall Street knew the loans were bad, but they didn’t care, they were making a fortune in the mortgage business and were all in. With Medicare Advantage plans, the moral hazard is the government (CMS) making risk-adjusted payments per MA patient, incentivizing upcoding to receive greater payments. In both cases, the opportunity to make lots of money now, despite knowing it’s not necessarily the right thing to do, wins out. Hence the term “moral hazard”. It’s a game of musical chairs, where everyone wins (except for taxpayers), right up until when the music stops playing.

[spinner1001]

So is that what happened here? The Medicare Advantage insurance companies were not over billed but Medicare overpaid on the capitation rate because TVH upcoded to make patients appear sicker than they actually were.

Even if you increased the capitation from $1,000 to $3,000, that would be $2,000 overpayment per patient so it would have to 45,000 patients to over bill $90,000,000.

That source is not necessarily the sole source of MA-related revenues TVH might receive. As I said, Medicare Advantage is complex. It’s not a simple HMO capitation model for medical clinics. Incentive bonuses and shared savings payments from CMS are among other possible sources of revenue for a MA clinic.

Anything specific about TVH is speculation since the records are not public.

[tophcfa]

That source is not necessarily the sole source of MA-related revenues TVH might receive. As I said, Medicare Advantage is complex. It’s not a simple HMO capitation model for medical clinics. Incentive bonuses and shared savings payments from CMS are among other possible sources of revenue for a MA clinic.

Anything specific about TVH is speculation since the records are not public.

TVH aside, is it safe to assume some of the revenue generated from upcoding is used by the Medicare Advantage Insurers to subsidize stuff like little to no monthly subscriber premiums, dental, hearing, vision, and other free stuff like health club memberships that aren’t available to those on traditional Medicare with a supplemental plan? It brings to mind the old adage, “if something seems too good to be true, then it’s most likely too good to be true”! There has to be a reason that Medicare pays, on average, 22% more per person on Advantage plans than traditional Medicare, despite the fact that people on traditional Medicare tend to be sicker and require more care? And if that is in fact the case, is it safe to expect the cost of Advantage plan premiums to increase and/or the benefits not available to traditional Medicare to begin to disappear?

[BrianL99]

Anything specific about TVH is speculation since the records are not public.

Most of it is subject to the Federal Freedom of Information act, so the finances are public, as is everything involving the so-call "fraud", once that's settled.

[Snowbirdtobe]

The bankruptcy proceedings open up many records. The amount of debt and the top debters are available on the court website. Even the Daily Sunny could find it. The pro-forma DIP plan is also in court documents. What the new operator of the facilities will do with the business is not public but may be revealed in court documents.
The stalking horse should find out where the money went so they don't become a Judas Goat.

I signed up for TVH when it first opened and in a year was so disappointed that I moved back to Medicare Plan F.

[CoachKandSportsguy]

Most of it is subject to the Federal Freedom of Information act, so the finances are public, as is everything involving the so-call "fraud", once that's settled.

The medical records by individual which was over coded is not available under the freedom of information act, that would be a patient privacy issue.

so even if they were available, not sure you can determine which was uploaded and which wasn't to get through the formulas to get to the overpayment amount. . .

[Rainger99]

Has the Morse family made any statement on the bankruptcy and the billing errors

The issue does not make the Villages look good so I would think that their public relations firm would try to get ahead of the issue.

[BrianL99]

The medical records by individual which was over coded is not available under the freedom of information act, that would be a patient privacy issue.

so even if they were available, not sure you can determine which was uploaded and which wasn't to get through the formulas to get to the overpayment amount. . .

It should all be available via FOI, other than patient names. If it was submitted to Medicare, it's a public document and subject to disclosure, with identifying information redacted.

There have been some posters who should have reasonable knowledge of what's been going on with TVH, but some media reports, suggest TVH's actions were more nefarious. I have no real clue how all this happened, but $361M seems far beyond a "misunderstanding" or "computer glitch". I have a former golfing partner who lost his medical license and served a significant prison sentence, for "over billing Medicare" and that was 7-8 years ago, before the Feds got real serious about routing out abuse.

"The Villages Health System LLC, which operates clinics for retirees living in the Villages in Central Florida, said in a July 3 court filing that it logged patient diagnoses that “were not clinically supported or otherwise did not meet Medicare coding and payment guidance.”"

(Villages Health System Sees $350 Million in Medicare Overcharges (https://www.insurancejournal.com/news/southeast/2025/07/09/830964.htm))

Call me crazy, but that sounds dangerously close to an admission of guilt.

[golfing eagles]

Villages Health where did all the money go?

A legitimate question. Let me speculate with an analogy, since I doubt it is under the CEO's mattress:

You own Snowbird Enterprises, a company that manufactures and sells widgets solely to the US Government at $2.00/widget. You start with one factory and a staff of 6, but your business grows fairly rapidly due to the demand for widgets. You make some profit, and use that to build more factories, hire more people and attract new professional widget makers. Maybe there's some cash, maybe not, since the books pretty much balance. And because you were dealing with a government bureaucracy, both when setting up your business and as an ongoing concern, you hired outside consultants to make sure you were doing everything right, including the pricing of widgets. Those auditors tell you all along that everything is being done by the book.

Time goes by, like 12 years, and you decide to sell your widget business, so you start negotiating with Widget Mart. To your dismay, they look at your widget pricing and tell you they disagree with the consultants you've hired----it is their opinion that you've been manufacturing type xyz5 widgets, which the government is only allowed, by law, to pay $1.50 each. You look at the difference between xyz5 and the xyz4 widgets that you've been selling, and it still isn't clear who's right since the definition of these widgets is extremely vague and subject to interpretation. So you report to the government that you MAY have been charging too much for widgets. And of course that agency agrees that they paid too much and you now owe them $360 million.

But you don't have $360 million, not even close. You have buildings, and equipment that is generally only good for making widgets, payroll, and bills for utilities and supplies, but no cash---because that's where the money went

Simplistic example, but the general message is accurate.

[golfing eagles]

.......

"The Villages Health System LLC, which operates clinics for retirees living in the Villages in Central Florida, said in a July 3 court filing that it logged patient diagnoses that “were not clinically supported or otherwise did not meet Medicare coding and payment guidance.”"

(Villages Health System Sees $350 Million in Medicare Overcharges (https://www.insurancejournal.com/news/southeast/2025/07/09/830964.htm))

Call me crazy, but that sounds dangerously close to an admission of guilt.

It sounds like an admission that a mistake was made, nothing more. Actually, it may indicate nothing more than a difference of opinion on exactly what the diagnostic and billing codes actually require to meet the criteria set forth.

[dewilson58]

Villages Health where did all the money go?

A legitimate question. Let me speculate with an analogy, since I doubt it is under the CEO's mattress: .................................................. .



That's one possibility, I heard it was because all the hospital patients were only drinking water and not buying off the menu.

:mornincoffee:

[golfing eagles]

That's one possibility, I heard it was because all the hospital patients were only drinking water and not buying off the menu.

:mornincoffee:

That was a subsidiary of TVH-----Katie Belle's :1rotfl::1rotfl::1rotfl:

[JeepsterGlenn]

The information is not in the public domain and likely will never be. I guess much (but not all) of the overpayments was/is with the MA insurance company(ies). See my first post how TVH health might be legally responsible for reimbursement. Only insiders and the government know. Others don’t.

I understand that inquiring minds want to know details but they likely will never get information. Come to think of it, there might be an opportunity for a new TV series about all of this.
================================================== =========================


Patients most likely also overpaid TVH facilities and doctors through their deductibles and copays due to the inflated procedure codes. For example if the procedure should have been coded to pay $100 and instead was coded to pay $200. Then the patient pays $200 in their deductible up to max deductible (and/or a percent of the $200 in their copay amount). Will these overpayments get reimbursements?

[BrianL99]

"The Villages Health System LLC, which operates clinics for retirees living in the Villages in Central Florida, said in a July 3 court filing that it logged patient diagnoses that “were not clinically supported or otherwise did not meet Medicare coding and payment guidance.”"

(Villages Health System Sees $350 Million in Medicare Overcharges (https://www.insurancejournal.com/news/southeast/2025/07/09/830964.htm))

Call me crazy, but that sounds dangerously close to an admission of guilt.

It sounds like an admission that a mistake was made, nothing more. Actually, it may indicate nothing more than a difference of opinion on exactly what the diagnostic and billing codes actually require to meet the criteria set forth.

I know nothing about being a doctor, but surely have some experience with government requirements and "forms".

I get what you're saying and it makes sense, other than the shear magnitude of the error. It seems unlikely that such a disagreement over interpretation or standards, could amass a discrepancy of $360,000,000. To quote Everett Dirksen, "a million here, a million there ... next thing you know, we're talking about real money".

[Altavia]

It sounds like an admission that a mistake was made, nothing more. Actually, it may indicate nothing more than a difference of opinion on exactly what the diagnostic and billing codes actually require to meet the criteria set forth.

I don't understand how an auditor who has never seen nor has access to the patient information can dispute a diagnosis?

What would the patient impact have been if treatment was based on the auditors diagnostic interpretation?

[lkagele]

Villages Health where did all the money go?
But you don't have $360 million, not even close. You have buildings, and equipment that is generally only good for making widgets, payroll, and bills for utilities and supplies, but no cash---because that's where the money went

Simplistic example, but the general message is accurate.

Not sure I really agree. Your theory might make sense with a business that produces products. TVH, however, provides services and the capital outlay to expand a service business is much less than is needed to expand manufacturing capabilities. The listed assets certainly don't indicate those overpayments went to purchase tangible assets.

Pfizer sold $100 billion in vaccines yet its stock went from the low 30's to the low 20's. So, just like Pfizer's profits, I think this overpayment money went somewhere it should not have.

[Joecooool]

I don't understand how some people are saying it was an over billing issue and its OK because they self reported.

What?

They get audited by the government. They probably self-reported because they knew they were going to get found out in an audit.

These Medicare Advantage Plan companies know full well what the rules and regulations are. They have legal teams, internal compliance officers, and they have to be trained and qualified to hold those positions.

No pass should be given to people who perpetrated this fraud against the American taxpayers. They need to be arrested, charged, convicted, fined, imprisoned, and then banned from ever working in the healthcare industry again.

But no way that will happen. Someone up top will make a political "donation", and all of this will be swept away with no one being held accountable.

Get caught stealing $750 worth of crap from Walmart, and you go to jail for 5 years. Defraud Medicare for hundreds of millions of dollars - and - well look what happened to Rick Scott... PolitiFact | Rick Scott '''oversaw the largest Medicare fraud''' in U.S. history, Florida Democratic Party says (https://www.politifact.com/factchecks/2014/mar/03/florida-democratic-party/rick-scott-rick-scott-oversaw-largest-medicare-fra/)

It's a big club, and you ain't in it.

[sallyg]

Overpayment is an interesting term.

[golfing eagles]

I don't understand how an auditor who has never seen nor has access to the patient information can dispute a diagnosis?

What would the patient impact have been if treatment was based on the auditors diagnostic interpretation?

What makes you think that TVH doesn't have outside auditors that they pay to consult on exactly these issues? (They do). The real question is: What happens when the auditors you pay say everything is OK but the auditors for a potential buyer says it's not? I suppose CMS gets the final word (they did), and the final word is "you owe us a lot of $$$"

[golfing eagles]

Not sure I really agree. Your theory might make sense with a business that produces products. TVH, however, provides services and the capital outlay to expand a service business is much less than is needed to expand manufacturing capabilities. The listed assets certainly don't indicate those overpayments went to purchase tangible assets.

Pfizer sold $100 billion in vaccines yet its stock went from the low 30's to the low 20's. So, just like Pfizer's profits, I think this overpayment money went somewhere it should not have.

Maybe, maybe not. I'm sure TVH will get to "entertain" an army of forensic accountants.

[golfing eagles]

I don't understand how some people are saying it was an over billing issue and its OK because they self reported.

What?

They get audited by the government. They probably self-reported because they knew they were going to get found out in an audit.

These Medicare Advantage Plan companies know full well what the rules and regulations are. They have legal teams, internal compliance officers, and they have to be trained and qualified to hold those positions.

No pass should be given to people who perpetrated this fraud against the American taxpayers. They need to be arrested, charged, convicted, fined, imprisoned, and then banned from ever working in the healthcare industry again.

But no way that will happen. Someone up top will make a political "donation", and all of this will be swept away with no one being held accountable.

Get caught stealing $750 worth of crap from Walmart, and you go to jail for 5 years. Defraud Medicare for hundreds of millions of dollars - and - well look what happened to Rick Scott... PolitiFact | Rick Scott '''oversaw the largest Medicare fraud''' in U.S. history, Florida Democratic Party says (https://www.politifact.com/factchecks/2014/mar/03/florida-democratic-party/rick-scott-rick-scott-oversaw-largest-medicare-fra/)

It's a big club, and you ain't in it.

And I don't understand how anyone can post that this was criminal fraud without knowing the facts or understanding the process. That's OK, as I said, the villagers are out with torches and pitchforks. I would prefer holding off on the accusation of criminal fraud until and unless the DOJ charges them and a judge/jury convicts them. But that's only American due process and presumption of innocence. Mob mentality on social media is much better :1rotfl::1rotfl::1rotfl:

[golfing eagles]

Overpayment is an interesting term.

The word isn't "interesting", it's "accurate"

[collie1228]

It sounds like an admission that a mistake was made, nothing more. Actually, it may indicate nothing more than a difference of opinion on exactly what the diagnostic and billing codes actually require to meet the criteria set forth.
Hold on a minute here. That statement was written by a lawyer and reviewed by several other lawyers before being put out there as a statement. I’m sorry, but I don’t think we can make any assumptions from a statement written by someone whose sole responsibility is to protect the subject.

[tophcfa]

Bigger picture thought here. Forget about upcoding responsibilities, intent, blame, where did the $$ go, etc…. The bigger picture here is that before this event came to light, the Villages already arguably had both not enough and substandard health care relative to the size of the senior population. For an area dominated by a senior population, where availability of quality healthcare is extremely important, this could have serious consequences. Think about it, the largest health care provider serving the community is now operating out of bankruptcy, holding on by a thread using DIP financing to stay operational while a bankruptcy court decides its fate. Like everyone else, I’ve read the carefully crafted public statements coming from TVH and CenterWell (Humana) about how this is all going to turn out wonderful for TVH patients. Unfortunately, it’s very difficult to envision a scenario where reality and those statements intersect. Make no mistake, Humana is a publicly traded company taking a strategic risk in acquiring TVH with the intent of vertical integration. Their strategy is to be the dominant health care provider in the ever growing senior marketplace. On the positive side for Humana, vertical integration can provide them with cost savings and effeciencies, which would lead to higher profits. On the negative side for patients, vertical integration can crowd out competition, leaving Humana with a quasi monopoly. For the consumer, competition is a wonderful thing. Think about a scenario where Comcast was the only internet provider in your area, not ideal to say the least.

Bottom line, this introduces more risk to a marketplace that already is pushing the health care system to the brink. Add to that the fact that the place is growing at a breakneck pace with no end in sight. I think that’s the big picture people should be focusing on.

[dpmers]

Traditional Medicare only pays 80% hence most of the 22% difference in payments for MA vs Traditional Medicare

[Burgy]

Yes and the old adage, "It was fun while it lasted", comes to mind. One wonders how much of this is going on all over the country.

Finally getting closer to the problem. Money goes from Medicare to Advantage Plan and then to TVH. And if you don't think the Advantage Plan isn't involved in the coding I seriously doubt it. Also involvement with Universities for research and new building may affect at what rate codes are paid. Interesting how UHC stock has tanked this year. Fraud. abuse, loopholes and mistakes can all be involved.

[golfing eagles]

Hold on a minute here. That statement was written by a lawyer and reviewed by several other lawyers before being put out there as a statement. I’m sorry, but I don’t think we can make any assumptions from a statement written by someone whose sole responsibility is to protect the subject.

I agree. Nor can we assume it means something different than what it states either.

[Snowbirdtobe]

They own no real estate as far as I can tell.
If the money was used to overpay docs and staff a new owner can't afford to maintain that.
If the money was used to over coddle the patients a new owner can't afford that.
Both of these things will be a problem for the patients trapped in TVH.
If the money was spent on making the Brownwood facility a wonderful place or burned in the parking lot that should have no effect on the ability for the new owner of serve the patients.

[Mikee1]

While the speculation goes on ... and on...
The next part is of more concern.
If Humana takes over, they have said they will treat all patients of Medicare and insurances.
This means more patients, in and outside of the Villages. Longer appointment times, etc, etc.
Add that to Humana's less than stellar reputation for care, may mean TVH is no longer an option for care. In that case, there is no excess availability of care options in the area....
Ponder that for a bit.
Yea, the money trail is interesting, but the above is more concerning, at least to me.

[justjim]

Suffice it to say the bankruptcy laws are way above my pay grade. Perhaps this man said it best: “These Capitalists generally act harmoniously and in concert, to fleece the people.” Abraham Lincoln January 11, 1837.

[Stu from NYC]

Villages Health where did all the money go?

A legitimate question. Let me speculate with an analogy, since I doubt it is under the CEO's mattress:

You own Snowbird Enterprises, a company that manufactures and sells widgets solely to the US Government at $2.00/widget. You start with one factory and a staff of 6, but your business grows fairly rapidly due to the demand for widgets. You make some profit, and use that to build more factories, hire more people and attract new professional widget makers. Maybe there's some cash, maybe not, since the books pretty much balance. And because you were dealing with a government bureaucracy, both when setting up your business and as an ongoing concern, you hired outside consultants to make sure you were doing everything right, including the pricing of widgets. Those auditors tell you all along that everything is being done by the book.

Time goes by, like 12 years, and you decide to sell your widget business, so you start negotiating with Widget Mart. To your dismay, they look at your widget pricing and tell you they disagree with the consultants you've hired----it is their opinion that you've been manufacturing type xyz5 widgets, which the government is only allowed, by law, to pay $1.50 each. You look at the difference between xyz5 and the xyz4 widgets that you've been selling, and it still isn't clear who's right since the definition of these widgets is extremely vague and subject to interpretation. So you report to the government that you MAY have been charging too much for widgets. And of course that agency agrees that they paid too much and you now owe them $360 million.

But you don't have $360 million, not even close. You have buildings, and equipment that is generally only good for making widgets, payroll, and bills for utilities and supplies, but no cash---because that's where the money went

Simplistic example, but the general message is accurate.

I would think that by examining TVH financial statements over the period in question can quickly determine where the money went. As I said earlier in this thread still think that Hamlet got it right, Something is Rotten in Denmark.

[Topspinmo]

And I don't understand how anyone can post that this was criminal fraud without knowing the facts or understanding the process. That's OK, as I said, the villagers are out with torches and pitchforks. I would prefer holding off on the accusation of criminal fraud until and unless the DOJ charges them and a judge/jury convicts them. But that's only American due process and presumption of innocence. Mob mentality on social media is much better :1rotfl::1rotfl::1rotfl:


Funny how innocent till proven guilty works when charged. O wait, you have to get lawyer to prove yourself innocence.

[Topspinmo]

The Villages has received over $361,000,000 in over payments from the FEDS.
The bankruptcy filings has the US taxpayers or Medicare listed as an unsecured creditor due 361 Million US $. Where is that money? That is $6500 per patient.
I noticed that the rent was paid to TV. The rent looks to be 1,135,000 per month, but no rent is forecast for October, Nov, or Dec in the pro-forma DIP budget.

“Villages Health where did all the money go”

Do you really have to ask that question?

[Justputt]

- The Villages Health (TVH) ran a unique business model for a large health care provider serving predominately a senior community. Unlike just about ever other similar health care provider, TVH primary care operation has not accept traditional medicare, only specific Medicare Advantage plans.

- Upcoding, when more diagnoses than are actually present are reported to increase medicare payments, are very rare with traditional Medicare and are almost exclusively limited to home care. On the other hand, upcoding has been widely abused with Medicare Advantage plans because under MA plans, payments are made on a risk-adjusted basis meaning higher risk scores (based on reported diagnoses) lead to higher payments.

- Despite the fact that patients with traditional Medicare and supplemental plans are generally sicker and require more health care than Medicare Advantage plan holders, Medicare Advantage plans pay out, on average, 22% more per patient than those with traditional Medicare.

- Without audited financial statements, including a detailed sources and uses of funds statement, it is impossible to figure out what happened to the $$$ referenced by the author of this thread. That being said, based on the bankruptcy filing information, the amount of reported assets relative to liabilities certainly indicates the money wasn't retained in THV surplus account.

The above Upcoding explanation is lacking. For a more complete understanding UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING? - PMC (https://pmc.ncbi.nlm.nih.gov/articles/PMC8649706/)

I don't know where this information came from as far as sicker population, but it doesn't match my 40 years' experience. Generally, government Medicare vs MA plans are chosen based on preferences, e.g. I have MA because it covers dental, vision, hearing, gym, etc. and government Medicare doesn't. Medicare doesn't have "network providers", you go where you chose that takes Medicare, whereas MA plans have a network and the plan you chose determines how broad the network (mine covers all my doctors here and all my doctors up north.) As for Medicare vs MA payments "The plans must follow rules and standards set by Medicare. The federal government pays Medicare Advantage plans to provide all Medicare-covered benefits. If there is a difference between the amount a Medicare Advantage plan is paid by Medicare and the plan’s actual cost to provide benefits, the plan must use any savings to provide additional benefits or reduce costs for members of the plan. This is how some Medicare Advantage plans provide coverage for services such as routine vision care and routine dental care, which are not covered by Medicare."

As for where the money went; Pre-COVID, our hospital operated very lean and ran in the back. Post-COVID, our hospital was grossing more than it had ever grossed and was losing $2M/month mostly because of staffing costs, since many left the medical field and were replaced by travelers at nearly 3x cost. I wouldn't assume the money did more than plug holes in a sinking ship.... but I could clearly be wrong and time will tell.

[CoachKandSportsguy]

From bing. . . whatever search engine

Beginning in 2025, CMS will conduct annual audits of every Medicare Advantage plan, which is a significant expansion from its previous practice of auditing roughly 60 plans per year.

TVH was probably too small to be one of the 60 lucky plans to be audited. .
so to assume that THV and every medicare Advantage Plan was government audited is wishful thinking. .

[lawgolfer]

- The Villages Health (TVH) ran a unique business model for a large health care provider serving predominately a senior community. Unlike just about ever other similar health care provider, TVH primary care operation has not accept traditional medicare, only specific Medicare Advantage plans.

- Upcoding, when more diagnoses than are actually present are reported to increase medicare payments, are very rare with traditional Medicare and are almost exclusively limited to home care. On the other hand, upcoding has been widely abused with Medicare Advantage plans because under MA plans, payments are made on a risk-adjusted basis meaning higher risk scores (based on reported diagnoses) lead to higher payments.

- Despite the fact that patients with traditional Medicare and supplemental plans are generally sicker and require more health care than Medicare Advantage plan holders, Medicare Advantage plans pay out, on average, 22% more per patient than those with traditional medicare.

- Without audited financial statements, including a detailed sources and uses of funds statement, it is impossible to figure out what happened to the $$$ referenced by the author of this thread. That being said, based on the bankruptcy filing information, the amount of reported assets relative to liabilities certainly indicates the money wasn't retained in THV surplus account.

- A Florida Bankruptcy Judge preliminarily approved a $39 million debtor-in-possession (known as DIP financing) plan for TVH. DIP financing is a last ditch effort to raise money, often when in bankruptcy proceedings, to stay in operation during restructuring. DIP lenders require extremely stringent terms to insure their capital is protected, such as hard collateral and being court selected to be the first to be paid within the debtors capital structure. Based on TVH's reported assets, there won't be much money left after paying off the DIP loan for either their other creditors and the money owed to Medicare.

- Below is a statement from Latham and Watkins, a firm hired to help CenterWell (Humana) in the acquisition of TVH Assets, while not taking on the Liabilities. One thing is for certain, CenterWell is diving into a hornets nest, as evident by the long list of attorneys with various areas of expertise, retained to guide them through this process. No one in their right mind would dive into a hornets nest without lots and lots of protection. One can only imagine how much money the health care provider will spend on attorneys fees, rather than providing health care.

The Villages Health (TVH), announced that it has entered into a "stalking horse" Asset Purchase Agreement with CenterWell Senior Primary Care, the nation's largest senior-focused value-based primary care provider. The agreement provides for CenterWell, the healthcare services business of Humana Inc., to acquire TVH's assets as a going concern, including eight primary care centers and two specialty care centers. A Court order approving the sale, following an auction process during which other parties may submit an offer to purchase TVH's assets, will be a condition of the transaction moving forward and closing.

Latham & Watkins LLP represents CenterWell in the transaction with a corporate deal team led by Washington, D.C. partner Brian Mangino and New York partner Amber Banks and New York counsel Richard Quay, with associates Alice Bradshaw, Lauren Stern, and Daniel Maggen. Advice was also provided on intellectual property matters by Washington, D.C. partner Morgan Brubaker, with associate Tyra Richmond; on healthcare regulatory matters by Washington, D.C. partners Jason Caron and Joseph Hudzik, Chicago partner Terra Reynolds, and Washington, D.C. counsel Nicole Liffrig Molife, with associates Chad Leiper, Megan Lich, Margaret Rote, and Danielle Scheer; on data privacy matters by Bay Area partner Heather Deixler, with associates Kathryn Parsons-Reponte and Priyanka Krishnamurthy Crissman; on insurance matters by Century City partner Kirsten Jackson and New York counsel Alexander Traum; on tax matters by Washington, D.C. partner Andrea Ramezan-Jackson, with associate Nolon Blaylock; on benefits matters by Washington, D.C. partner David Della Rocca and Washington, D.C. counsel Laura Szarmach, with associate Rebecca Fishbein; on labor matters by New York counsel Sandra Benjamin, with associate Jenny Bobbitt; on real estate matters by New York partner Dara Denberg and New York counsel Shira Bressler, with associate Sarah Jeon; on finance matters by New York partner Kendra Kocovsky, with associate Benedict Bussmann; on environmental matters by New York counsel David Langer, with associate Tal Carmeli; and on restructuring matters by Washington, D.C./New York partner Andrew Sorkin and Chicago partner Caroline Reckler, with associates Isaac Ashworth and Brian Rosen.

- Just reporting some relevant facts here, what actually happened to the $$ is up to ones interoperation of the facts.

As a retired litigation attorney, I stand in awe of CenterWell employing 39 attorneys to handle the acquisition of The Villages Health. Between the lawyers and the lender providing DIP financing, the bones of TVH will be picked clean and bleached as white as if they had laid for years in the desert.

[CoachKandSportsguy]

As a retired litigation attorney, I stand in awe of CenterWell employing 39 attorneys to handle the acquisition of The Villages Health. Between the lawyers and the lender providing DIP financing, the bones of TVH will be picked clean and bleached as white as if they had laid for years in the desert.

WOW!

and so the increasing cost of medical insurance must be driven by the legal system. .

:boom:

:censored: :mad: :throwtomatoes:

[jimschlaefer]

The Villages has received over $361,000,000 in over payments from the FEDS.
The bankruptcy filings has the US taxpayers or Medicare listed as an unsecured creditor due 361 Million US $. Where is that money? That is $6500 per patient.
I noticed that the rent was paid to TV. The rent looks to be 1,135,000 per month, but no rent is forecast for October, Nov, or Dec in the pro-forma DIP budget.

To add to your "where is the money" question; let's just assume it was all used to support TVHC services and quality. If that were the case, and this revenue source is no longer going to be legally available, what services and quality will suffer? Hmmmm

[Stu from NYC]

As a retired litigation attorney, I stand in awe of CenterWell employing 39 attorneys to handle the acquisition of The Villages Health. Between the lawyers and the lender providing DIP financing, the bones of TVH will be picked clean and bleached as white as if they had laid for years in the desert.

Full employment for lawyers. We should make 90% of the lawyers find another career that would help our economy.

[OrangeBlossomBaby]

================================================== =========================


Patients most likely also overpaid TVH facilities and doctors through their deductibles and copays due to the inflated procedure codes. For example if the procedure should have been coded to pay $100 and instead was coded to pay $200. Then the patient pays $200 in their deductible up to max deductible (and/or a percent of the $200 in their copay amount). Will these overpayments get reimbursements?

That's not how Medicare Advantage works. This didn't affect the patient's billing AT ALL.

[OrangeBlossomBaby]

Funny how innocent till proven guilty works when charged. O wait, you have to get lawyer to prove yourself innocence.

No need for a lawyer if you're not being charged with anything.

The Government isn't charging TVH with anything. The overpayments happened in 2024, not in 2025. This isn't something new or all that recent. There is no current fraud investigation happening with TVH as a target.

[OrangeBlossomBaby]

From bing. . . whatever search engine

Beginning in 2025, CMS will conduct annual audits of every Medicare Advantage plan, which is a significant expansion from its previous practice of auditing roughly 60 plans per year.

TVH was probably too small to be one of the 60 lucky plans to be audited. .
so to assume that THV and every medicare Advantage Plan was government audited is wishful thinking. .

The auditing at TVH took place in 2024.

[tophcfa]

Traditional Medicare only pays 80% hence most of the 22% difference in payments for MA vs Traditional Medicare

You’re missing the point entirely. The government doesn’t care how much private insurance companies pay, they care about how much they pay out of the rapidly dwindling Medicare fund. Medicare Advantage plans were created in an attempt to team up with private insurance companies, as an alternative to traditional Medicare, in an effort to save costs and help shore up the Medicare financial situation. So far, the experiment has failed miserably. Despite the aggregate population of traditional Medicare subscribers being sicker than the Medicare Advantage population, it is estimated that Medicare pays 22% more for Medicare Advantage enrollees than it would have spent if those beneficiaries were enrolled in traditional Medicare. That’s an amount that translates into $83 billion for 2024 alone. And if you don’t want to believe me, look it up. It was reported to congress by MedPac, a nonpartisan and independent legislative branch charged with providing the US congress with analysis and policy advice on the Medicare program. The bottom line here is that something has to give with the whole Medicare Advantage program, it’s not working as intended.

[Joecooool]

Medicare Advantage plans were created in an attempt to team up with private insurance companies, as an alternative to traditional Medicare, in an effort to save costs and help shore up the Medicare financial situation.

It was created by Congress after the insurance lobby bribed them into it. The only intention was to move government funded care into private insurance firms. That's it. Any benefit that would have ever happened would have been purely a coincidence.

And of course that didn't happen.

[Rainger99]

It is estimated that Medicare pays 22% more for Medicare Advantage enrollees than it would have spent if those beneficiaries were enrolled in traditional Medicare. That’s an amount that translates into $83 billion for 2024 alone….The bottom line here is that something has to give with the whole Medicare Advantage program, it’s not working as intended.

If MA was supposed to save the government money but is actually costing more, do people expect MA to be abolished?

[tophcfa]

If MA was supposed to save the government money but is actually costing more, do people expect MA to be abolished?

Perhaps, but a more likely scenario would be that Medicare pays less to private insurers per patient, forcing up Medicare Advantage premiums and resulting in less benefits being offered that are not offered to traditional Medicare subscribers. Those benefits could include things like Dental, Vision, and Hearing coverage as well as stuff like free health club membership. If that happens, many more new Medicare enrollees are likely to select traditional Medicare, with a supplemental plan, versus Medicare Advantage plans. Those currently on MA plans are also more likely to switch to traditional Medicare, assuming they can pass medical underwriting.

[CoachKandSportsguy]

The auditing at TVH took place in 2024.

most likely the first time, so the upcoding occurred for several years to get to 300+ million. However, the point of the post is that many assume that all MA plans are audited by CMS, and that is not correct.

Also, I didn't read by whom the audit was performed, CMS or independent / non CMS for TVH, but I read alot about everyone being audited by CMS. . . I doubt the Leapfrog did their audit to find the issue.

[tophcfa]

most likely the first time, so the upcoding occurred for several years to get to 300+ million. However, the point of the post is that many assume that all MA plans are audited by CMS, and that is not correct.

Also, I didn't read by whom the audit was performed, CMS or independent / non CMS for TVH, but I read alot about everyone being audited by CMS. . . I doubt the Leapfrog did their audit to find the issue.

And auditing for coding accuracy is not the same as having their financials audited. Since TVH is not a public entity, having their financials audited is optional, unless required by those extending credit to them.

[mtdjed]

If MA was supposed to save the government money but is actually costing more, do people expect MA to be abolished?

Follow the money. I am on traditional Medicare with a supplement. Last year I paid Medicare Part B $175/Month and my supplement was about $200 a month with a yearly Deductible of $240 and co-pays of $20 per visit. Not much opportunity for me to overcharge.

Providers must the use government CMS provided diagnostic codes which define how much they will be paid. Surely some providers may abuse the codes but there are two levels of authority above (CMS and Supplement Plan) to monitor.

About the only giveaway is Health Cub membership free which my supplement provides.

That is OK with me, as it is my choice and we happen to use. If it wasn't OK , I would be feeling that I was being overcharged by $60 a month.

With Medicare Advantage most of the control is transferred to the Medicare Advantage. They establish the Price of support, establish provider payments, and feedback to Medicare.

For failure I would say that the Medicare Provider is the Guilty party. They did not do their job.

[Rainger99]

According to data from the Medicare Payment Advisory Commission (MedPAC) and other analyses, Medicare's average annual spending per beneficiary in traditional Medicare is approximately $12,000 to $14,000.

Estimates from MedPAC (2024) suggest that Medicare Advantage plans cost Medicare about 22% more than traditional Medicare, implying an average annual cost of approximately $14,500 to $16,000 per enrollee in 2024.

[mraines]

================================================== =========================


Patients most likely also overpaid TVH facilities and doctors through their deductibles and copays due to the inflated procedure codes. For example if the procedure should have been coded to pay $100 and instead was coded to pay $200. Then the patient pays $200 in their deductible up to max deductible (and/or a percent of the $200 in their copay amount). Will these overpayments get reimbursements?
So, I guess I don't understand how you overcharge and file bankruptcy.

[Stu from NYC]

So, I guess I don't understand how you overcharge and file bankruptcy.

Takes a special kind of talent to do this in huge amounts.

[Topspinmo]

No need for a lawyer if you're not being charged with anything.

The Government isn't charging TVH with anything. The overpayments happened in 2024, not in 2025. This isn't something new or all that recent. There is no current fraud investigation happening with TVH as a target.


Close to half billion in overcharging and no investigation. Priceless.

[OrangeBlossomBaby]

Close to half billion in overcharging and no investigation. Priceless.

None needed. It was made transparent. TVH performed an audit (it wasn't the IRS forcing them to get audited, this wasn't a government investigational audit). They caught a really large flaw in their coding processes, that resulted in millions of dollars over a 4-year period being billed to insurance, that would've been less if they'd used the correct billing code. I'll lay it out again here since it's obviously been missed from my previous post somewhere on this forum:

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

The billing department receives the notation from the doctor's office that the patient had a checkup, AND that the patient came in with a lesion they needed to discuss.

The billing department mistakes this for two separate visits, and bills P1301 and P1462, for a total of $370. The patient pays nothing since both are still covered at 100%. TVH gets paid $370.

There's no fraud. Both of these things happened, no one is lying, no one is intending to steal money from anyone. But the people in the billing office probably had never seen these as the SAME VISIT before, and had always billed it out as separate codes, and never thought they'd need to check to find out if there was a different code for that. So they did this for EVERY patient who came into the office for a checkup, with a lesion they wanted to talk to the doctor about.

Just $170 overage, but multiply that by thousands of patients, and the billing department making the same miscode for four years in a row, and you're looking at millions of dollars in erroneous coding and erroneous payouts. The patient never sees a bill, because it's all covered. And when they look at their monthly explanation of benefits, they see exactly what they experienced: they went in for a checkup. They also discussed a lesion with the doctor.

The above example is hypothetical. Insert whatever made-up code you want, and insert any similar types of errors you want. Checkup + skin lesion is mine. Full physical with EKG for patients who are planning on getting surgery, versus full physical with EKG, plus new consultation for pre-surgery.

Any time there's a visit with a combination of "things the doctor does" there's a chance that there are a few different coding options. The doctor doesn't know billing codes. That's not his job. The billing office doesn't get to see the full notes of the doctor. It's none of their business. The doctor passes the notes to the office folks, who plug in what they believe the procedure numbers are, into the patient's billing file. The billing file gets forwarded to the billing office. The billing office determines the billing code to match the procedure codes, and the system spits out a bill.

Somewhere between the doctor's input and the bill to insurance, there were consistent errors. Likely something similar to the example I made above. Procedures that are fairly routine, that would be lumped together with one code if they happened on the same visit but have two separate codes, with two different fees charged, if they happen on different visits (even if those visits are consecutive, with one only 10 minutes after the other).

The habit of miscoding whatever the procedures were, happened as a convention, not as an intention to defraud anyone.

[Topspinmo]

None needed. It was made transparent. TVH performed an audit (it wasn't the IRS forcing them to get audited, this wasn't a government investigational audit). They caught a really large flaw in their coding processes, that resulted in millions of dollars over a 4-year period being billed to insurance, that would've been less if they'd used the correct billing code. I'll lay it out again here since it's obviously been missed from my previous post somewhere on this forum:

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

The billing department receives the notation from the doctor's office that the patient had a checkup, AND that the patient came in with a lesion they needed to discuss.

The billing department mistakes this for two separate visits, and bills P1301 and P1462, for a total of $370. The patient pays nothing since both are still covered at 100%. TVH gets paid $370.

There's no fraud. Both of these things happened, no one is lying, no one is intending to steal money from anyone. But the people in the billing office probably had never seen these as the SAME VISIT before, and had always billed it out as separate codes, and never thought they'd need to check to find out if there was a different code for that. So they did this for EVERY patient who came into the office for a checkup, with a lesion they wanted to talk to the doctor about.

Just $170 overage, but multiply that by thousands of patients, and the billing department making the same miscode for four years in a row, and you're looking at millions of dollars in erroneous coding and erroneous payouts. The patient never sees a bill, because it's all covered. And when they look at their monthly explanation of benefits, they see exactly what they experienced: they went in for a checkup. They also discussed a lesion with the doctor.

The above example is hypothetical. Insert whatever made-up code you want, and insert any similar types of errors you want. Checkup + skin lesion is mine. Full physical with EKG for patients who are planning on getting surgery, versus full physical with EKG, plus new consultation for pre-surgery.

Any time there's a visit with a combination of "things the doctor does" there's a chance that there are a few different coding options. The doctor doesn't know billing codes. That's not his job. The billing office doesn't get to see the full notes of the doctor. It's none of their business. The doctor passes the notes to the office folks, who plug in what they believe the procedure numbers are, into the patient's billing file. The billing file gets forwarded to the billing office. The billing office determines the billing code to match the procedure codes, and the system spits out a bill.

Somewhere between the doctor's input and the bill to insurance, there were consistent errors. Likely something similar to the example I made above. Procedures that are fairly routine, that would be lumped together with one code if they happened on the same visit but have two separate codes, with two different fees charged, if they happen on different visits (even if those visits are consecutive, with one only 10 minutes after the other).

The habit of miscoding whatever the procedures were, happened as a convention, not as an intention to defraud anyone.

All that Don’t explain where the money went, it explains how it was taken either accidentally or intentionally?

[golfing eagles]

All that Don’t explain where the money went, it explains how it was taken either accidentally or intentionally?

It went wherever it went. Don't look at this as "extra money" separate from day to day operations. This was the revenue that they expected and believed was correct to receive, so it went to expansion, equipment, additional personnel, salaries, utilities, paving the parking lot, whatever. Their own outside auditors believed the coding was correct. NO FRAUD. NO CRIMINAL INTENT. NO CHARGES. NO INVESTIGATION. NO SLUSH FUND UNDER THE CEO'S MATTRESS. JUST A MISTAKE/DIFFERENCE OF OPINION ON CODING. Unfortunately for TVH, CMS gets the last opinion.

[Joecooool]

None needed. It was made transparent. TVH performed an audit (it wasn't the IRS forcing them to get audited, this wasn't a government investigational audit). They caught a really large flaw in their coding processes, that resulted in millions of dollars over a 4-year period being billed to insurance, that would've been less if they'd used the correct billing code. I'll lay it out again here since it's obviously been missed from my previous post somewhere on this forum:

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

The billing department receives the notation from the doctor's office that the patient had a checkup, AND that the patient came in with a lesion they needed to discuss.

The billing department mistakes this for two separate visits, and bills P1301 and P1462, for a total of $370. The patient pays nothing since both are still covered at 100%. TVH gets paid $370.

There's no fraud. Both of these things happened, no one is lying, no one is intending to steal money from anyone. But the people in the billing office probably had never seen these as the SAME VISIT before, and had always billed it out as separate codes, and never thought they'd need to check to find out if there was a different code for that. So they did this for EVERY patient who came into the office for a checkup, with a lesion they wanted to talk to the doctor about.

Just $170 overage, but multiply that by thousands of patients, and the billing department making the same miscode for four years in a row, and you're looking at millions of dollars in erroneous coding and erroneous payouts. The patient never sees a bill, because it's all covered. And when they look at their monthly explanation of benefits, they see exactly what they experienced: they went in for a checkup. They also discussed a lesion with the doctor.

The above example is hypothetical. Insert whatever made-up code you want, and insert any similar types of errors you want. Checkup + skin lesion is mine. Full physical with EKG for patients who are planning on getting surgery, versus full physical with EKG, plus new consultation for pre-surgery.

Any time there's a visit with a combination of "things the doctor does" there's a chance that there are a few different coding options. The doctor doesn't know billing codes. That's not his job. The billing office doesn't get to see the full notes of the doctor. It's none of their business. The doctor passes the notes to the office folks, who plug in what they believe the procedure numbers are, into the patient's billing file. The billing file gets forwarded to the billing office. The billing office determines the billing code to match the procedure codes, and the system spits out a bill.

Somewhere between the doctor's input and the bill to insurance, there were consistent errors. Likely something similar to the example I made above. Procedures that are fairly routine, that would be lumped together with one code if they happened on the same visit but have two separate codes, with two different fees charged, if they happen on different visits (even if those visits are consecutive, with one only 10 minutes after the other).

The habit of miscoding whatever the procedures were, happened as a convention, not as an intention to defraud anyone.

Are you seriously suggesting that a for-profit business didn't notice they ended up with an extra couple hundred million dollars?

[golfing eagles]

Are you seriously suggesting that a for-profit business didn't notice they ended up with an extra couple hundred million dollars?

Again, and hopefully for the last time: It was coded, it was billed, and they received the money. It was expected; it WAS NOT EXTRA. This is not really all that hard to understand. If you sell 100 bananas at $1.00 each, you receive $100. You use it to buy more bananas, build a better banana stand and go out for dinner. There is no problem until some entity comes along and says: You can only sell bananas for $0.75 in this county, you owe $100,000 for "overbilling" the last 4 years. Now you go bankrupt. There is no secret pile of cash to pay back. You have to sell your new banana stand, liquidate your inventory of bananas and hope to find a willing buyer to take over the banana business since the people need bananas. Simple.

[Stu from NYC]

Again, and hopefully for the last time: It was coded, it was billed, and they received the money. It was expected; it WAS NOT EXTRA. This is not really all that hard to understand. If you sell 100 bananas at $1.00 each, you receive $100. You use it to buy more bananas, build a better banana stand and go out for dinner. There is no problem until some entity comes along and says: You can only sell bananas for $0.75 in this county, you owe $100,000 for "overbilling" the last 4 years. Now you go bankrupt. There is no secret pile of cash to pay back. You have to sell your new banana stand, liquidate your inventory of bananas and hope to find a willing buyer to take over the banana business since the people need bananas. Simple.

I think you are overlooking an important factor. Profits and available cash go up and granted money is spent for expansion but also salaries and dividends to the owners go up and can go up substantially.

[golfing eagles]

I think you are overlooking an important factor. Profits and available cash go up and granted money is spent for expansion but also salaries and dividends to the owners go up and can go up substantially.

Of course, and that also balances the books. Did the owners of TVH make money? I don't know but it's likely. If you look at the bankruptcy filing, you'll see that many of the physicians are small shareholders, like 0.0025% each, but they have not received a penny from that share of ownership. But my point is that the money received from the so-called overbilling is not extra---it was simply what they expected and no one disagreed--not their outside auditors, not CMS----until.............and we all know the rest so far.

[Rainger99]

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.

A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

But in your example, Advantage covers it. As I understand it, Advantage pays claims out of their capitation payment. If the payment per patient is less than the capitation payment, Advantage pockets the money. If they pay more, Advantage loses money. That is why Advantage has an incentive to deny claims. See the posting about the doctor trying to get authorization from UHC for a procedure

Medicare wasn't defrauded - Advantage was. Why isn't UHC on of the biggest creditors?

[Rainger99]

Again, and hopefully for the last time: It was coded, it was billed, and they received the money. It was expected; it WAS NOT EXTRA. This is not really all that hard to understand. If you sell 100 bananas at $1.00 each, you receive $100. You use it to buy more bananas, build a better banana stand and go out for dinner. There is no problem until some entity comes along and says: You can only sell bananas for $0.75 in this county, you owe $100,000 for "overbilling" the last 4 years. Now you go bankrupt. There is no secret pile of cash to pay back. You have to sell your new banana stand, liquidate your inventory of bananas and hope to find a willing buyer to take over the banana business since the people need bananas. Simple.

But if you sell 100 bananas in 2020 and make $100 wouldn't you be suspicious if you sold 110 bananas in 2021 and made $200?

[golfing eagles]

But if you sell 100 bananas in 2020 and make $100 wouldn't you be suspicious if you sold 110 bananas in 2021 and made $200?

Not what happened

[Joecooool]

Again, and hopefully for the last time: It was coded, it was billed, and they received the money. It was expected; it WAS NOT EXTRA. This is not really all that hard to understand. If you sell 100 bananas at $1.00 each, you receive $100. You use it to buy more bananas, build a better banana stand and go out for dinner. There is no problem until some entity comes along and says: You can only sell bananas for $0.75 in this county, you owe $100,000 for "overbilling" the last 4 years. Now you go bankrupt. There is no secret pile of cash to pay back. You have to sell your new banana stand, liquidate your inventory of bananas and hope to find a willing buyer to take over the banana business since the people need bananas. Simple.
Why are you here acting as an apologist for these thieves? You can justify it with whatever nonsense you want, but the fact remains that they had people on staff to monitor these things.

This was fraud against we Americans. And I hope those involved GO TO JAIL.

[Rainger99]

Not what happened

Tell us what happened.

[golfing eagles]

Why are you here acting as an apologist for these thieves? You can justify it with whatever nonsense you want, but the fact remains that they had people on staff to monitor these things.

This was fraud against we Americans. And I hope those involved GO TO JAIL.

Wow, that's an easy question to answer:

1) THEY ARE NOT THIEVES
2) My posts are based on expertise in health care, generally it is nonsense that I am responding to (like now)
3) They not only had people on staff, but outside consultants, and they were told their coding was fine, which only goes to show how vague many of these diagnostic codes are.
4) THERE IS NO OFFICIAL ACCUSATION OF, NOR INVESTIGATION OF FRAUD
5) YOU don't get to send people to jail, a judge and jury does.

So, take another look at who has posted "nonsense", I would suggest you need a mirror

[golfing eagles]

Tell us what happened.

I've already explained it 3 different ways. In the last analogy, the banana company NEVER got unexpected revenue from the sale of bananas, they got the $100 they expected. Only after years of selling them at $1 each did they find out, or at least there was an opinion out there, that they should have only been charging $0.75 each

[MX rider]

I've already explained it 3 different ways. In the last analogy, the banana company NEVER got unexpected revenue from the sale of bananas, they got the $100 they expected. Only after years of selling them at $1 each did they find out, or at least there was an opinion out there, that they should have only been charging $0.75 each

I understood you first explanation. lol
Not sure why some on here can't get what you're saying.
Thanks anyway for helping us understand the situation more clearly.

[Rainger99]

I've already explained it 3 different ways. In the last analogy, the banana company NEVER got unexpected revenue from the sale of bananas, they got the $100 they expected. Only after years of selling them at $1 each did they find out, or at least there was an opinion out there, that they should have only been charging $0.75 each

As far as I can tell, the over billing is only for the past four years. TVH started operating in 2012. What happened in 2021 to create the billing issues? Were they charging $.75 per banana from 2012 to 2021? And then they decided to raise the price of bananas?

The website says it has 55,000 patients. If you divide $360,000,000 by 55,000 that is about $6500 per patient or more than $1,500 per patient per year. Those bananas are more expensive than buying them at Publix.

TVH may have a perfect explosion for the billing discrepancy.

But if it is as innocent as you say, why doesn’t TVH or their lawyers explain it to us?

[golfing eagles]

As far as I can tell, the over billing is only for the past four years. TVH started operating in 2012. What happened in 2021 to create the billing issues? Were they charging $.75 per banana from 2012 to 2021? And then they decided to raise the price of bananas?

The website says it has 55,000 patients. If you divide $360,000,000 by 55,000 that is about $6500 per patient or more than $1,500 per patient per year. Those bananas are more expensive than buying them at Publix.

TVH may have a perfect explosion for the billing discrepancy.

But if it is as innocent as you say, why doesn’t TVH or their lawyers explain it to us?

I said it could be innocent, even probably, but time will tell. What I've been against is posters that state it is definitely fraud and they should go to jail, when they don't have the slightest idea how this works, or they think 5 minutes on google makes them an expert.

[OrangeBlossomBaby]

Close to half billion in overcharging and no investigation. Priceless.

All that Don’t explain where the money went, it explains how it was taken either accidentally or intentionally?

Someone else had already explained what happened to the money. I was responding to your post, where you commented that close to half a billion was overcharged with no investigation (as quoted above).

[Caymus]

Of course, and that also balances the books. Did the owners of TVH make money? I don't know but it's likely. If you look at the bankruptcy filing, you'll see that many of the physicians are small shareholders, like 0.0025% each, but they have not received a penny from that share of ownership. But my point is that the money received from the so-called overbilling is not extra---it was simply what they expected and no one disagreed--not their outside auditors, not CMS----until.............and we all know the rest so far.

Maybe the bankruptcy court will investigate and crawl back some of the payments.

[BrianL99]

I said it could be innocent, even probably, but time will tell. What I've been against is posters that state it is definitely fraud and they should go to jail, when they don't have the slightest idea how this works, or they think 5 minutes on google makes them an expert.

If they've been getting $110 a bunch, for bananas that were only worth $100, they must be pretty lousy business managers if all the money is gone.

[golfing eagles]

If they've been getting $110 a bunch, for bananas that were only worth $100, they must be pretty lousy business managers if all the money is gone.

Or they have assets worth $10

[JustSomeGuy]

None needed. It was made transparent. TVH performed an audit (it wasn't the IRS forcing them to get audited, this wasn't a government investigational audit). They caught a really large flaw in their coding processes, that resulted in millions of dollars over a 4-year period being billed to insurance, that would've been less if they'd used the correct billing code. I'll lay it out again here since it's obviously been missed from my previous post somewhere on this forum:

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

The billing department receives the notation from the doctor's office that the patient had a checkup, AND that the patient came in with a lesion they needed to discuss.

The billing department mistakes this for two separate visits, and bills P1301 and P1462, for a total of $370. The patient pays nothing since both are still covered at 100%. TVH gets paid $370.

There's no fraud. Both of these things happened, no one is lying, no one is intending to steal money from anyone. But the people in the billing office probably had never seen these as the SAME VISIT before, and had always billed it out as separate codes, and never thought they'd need to check to find out if there was a different code for that. So they did this for EVERY patient who came into the office for a checkup, with a lesion they wanted to talk to the doctor about.

Just $170 overage, but multiply that by thousands of patients, and the billing department making the same miscode for four years in a row, and you're looking at millions of dollars in erroneous coding and erroneous payouts. The patient never sees a bill, because it's all covered. And when they look at their monthly explanation of benefits, they see exactly what they experienced: they went in for a checkup. They also discussed a lesion with the doctor.

The above example is hypothetical. Insert whatever made-up code you want, and insert any similar types of errors you want. Checkup + skin lesion is mine. Full physical with EKG for patients who are planning on getting surgery, versus full physical with EKG, plus new consultation for pre-surgery.

Any time there's a visit with a combination of "things the doctor does" there's a chance that there are a few different coding options. The doctor doesn't know billing codes. That's not his job. The billing office doesn't get to see the full notes of the doctor. It's none of their business. The doctor passes the notes to the office folks, who plug in what they believe the procedure numbers are, into the patient's billing file. The billing file gets forwarded to the billing office. The billing office determines the billing code to match the procedure codes, and the system spits out a bill.

Somewhere between the doctor's input and the bill to insurance, there were consistent errors. Likely something similar to the example I made above. Procedures that are fairly routine, that would be lumped together with one code if they happened on the same visit but have two separate codes, with two different fees charged, if they happen on different visits (even if those visits are consecutive, with one only 10 minutes after the other).

The habit of miscoding whatever the procedures were, happened as a convention, not as an intention to defraud anyone.

Every year they must create a budget. First year of over charges, no matter the reason, even if everything added up, someone would have seen that they exceeded their expected office visits by 100% and revenues by a similar amount using the above example. Big red flag missed... or ignored (likely). Next year they use those over inflated "codings" to set the budget.... and so on. Funds were used (Hmmm) for salaries and offices to handle the workload of the miss coded visits. If that were the case those seeking care would have seen almost half the appointment slots unused (if the villages healthcare did not know there was an error), doctors seeing half the expected appointments and half empty waiting rooms... every year since the first miscoding (which in the example double counted appointments, half bogus).

If they used the funds for other purposes, profit, overpaid the doctors and staff or overpaid on rent and did not expand staff and doctors then the funds disappear but patients notice no over staffing. The organization "knew" something was wrong since they were doing twice the business with the same staff.

If any other non-government business did this someone would be found at fault.

If they truly thought the billings were correct then those who will still be using the "new company" should see the staff (including Doctors) reduced significantly and offices downsized or closed since they inflated the workload and income by miscoding as noted in the example above.

Someone got the hundreds of millions they can't repay and which caused the bankruptcy. Time will tell who. If they do not cut the number of Doctors and staff, then it went somewhere else and that needs to be investigated.

[Rainger99]

According to an AI search, the largest case of Medicare overcharging that wasn’t classified as a criminal matter appears to be the settlement involving Independent Health Association and its affiliate, Independent Health Corporation, announced on December 20, 2024. They agreed to pay up to $98 million to resolve allegations under the False Claims Act for knowingly submitting invalid diagnosis codes to Medicare for Medicare Advantage Plan enrollees to inflate payments. This was a civil settlement, not a criminal case, as it focused on improper billing practices without criminal charges.

[golfing eagles]

Every year they must create a budget. First year of over charges, no matter the reason, even if everything added up, someone would have seen that they exceeded their expected office visits by 100% and revenues by a similar amount using the above example. Big red flag missed... or ignored (likely). Next year they use those over inflated "codings" to set the budget.... and so on. Funds were used (Hmmm) for salaries and offices to handle the workload of the miss coded visits. If that were the case those seeking care would have seen almost half the appointment slots unused (if the villages healthcare did not know there was an error), doctors seeing half the expected appointments and half empty waiting rooms... every year since the first miscoding (which in the example double counted appointments, half bogus).

If they used the funds for other purposes, profit, overpaid the doctors and staff or overpaid on rent and did not expand staff and doctors then the funds disappear but patients notice no over staffing. The organization "knew" something was wrong since they were doing twice the business with the same staff.

If any other non-government business did this someone would be found at fault.

If they truly thought the billings were correct then those who will still be using the "new company" should see the staff (including Doctors) reduced significantly and offices downsized or closed since they inflated the workload and income by miscoding as noted in the example above.

Someone got the hundreds of millions they can't repay and which caused the bankruptcy. Time will tell who. If they do not cut the number of Doctors and staff, then it went somewhere else and that needs to be investigated.

Wrong, wrong and even more WRONG.

They did not believe there were "overcharges", therefore they did not exceed their expected revenue. And the "number of visits" is irrelevant with MA plans. I don't understand why this concept is so difficult to grasp, their budget was based on the LEGITIMATE expectation of revenue based on their number of patients and diagnostic mix, with outside consultants indicating that their coding was OK. There is nothing "extra". There is no slush fund or secret account. Nobody got hundreds of millions. There is no charge of fraud and no investigation because it is NOT NEEDED. Apparently, they have agreed to a settlement of what CMS considers a mistake in coding.

[Joecooool]

Wow, that's an easy question to answer:

1) THEY ARE NOT THIEVES
2) My posts are based on expertise in health care, generally it is nonsense that I am responding to (like now)
3) They not only had people on staff, but outside consultants, and they were told their coding was fine, which only goes to show how vague many of these diagnostic codes are.
4) THERE IS NO OFFICIAL ACCUSATION OF, NOR INVESTIGATION OF FRAUD
5) YOU don't get to send people to jail, a judge and jury does.

So, take another look at who has posted "nonsense", I would suggest you need a mirrorThere are many people here that are "experts" on health care issues. There are not many agreeing with you.

Certified claims and billing staff within Medicare Advantage (MA) plans are crucial to ensuring that claims are processed accurately, in compliance with CMS regulations, and with proper documentation. Their primary responsibility is to submit and process claims by reviewing patient records to ensure that submitted claims align with diagnoses and procedures. They must verify the patient's eligibility for Medicare benefits and ensure proper coding and documentation for accurate reimbursement. These professionals are also responsible for medical coding, which is the conversion of healthcare diagnoses, procedures, medical services, and equipment into standardized codes, such as ICD-10 for diagnoses, CPT for procedures, and HCPCS for supplies. Accurate coding is essential for proper billing and reimbursement, as errors can lead to overpayment, underpayment, or potential fraud.

A key aspect of the job is managing risk adjustment, which involves assigning appropriate codes based on the health status of beneficiaries. Medicare Advantage plans rely on risk adjustment models, such as HCC (Hierarchical Condition Categories), to adjust payments according to the health conditions of beneficiaries. Claims and billing staff must ensure that the diagnoses submitted align with these models and that the documentation accurately supports the codes used. Additionally, fraud prevention is a critical responsibility, with billing staff trained to identify and prevent issues like upcoding, unbundling, and falsifying patient information. Medicare Advantage plans are held to strict fraud and abuse laws, and staff must be vigilant in ensuring compliance.

Claims and billing staff are also involved in audits and reporting, particularly in Risk Adjustment Data Validation (RADV) audits, where CMS ensures that submitted diagnoses are substantiated by medical records. Maintaining compliance with Medicare regulations (42 CFR Part 422), HIPAA privacy rules, and ongoing fraud detection efforts is essential. Regular reporting and participation in audits help ensure that the claims process remains transparent and accurate.

To ensure competency, claims and billing professionals must hold certifications that demonstrate their expertise. The Certified Professional Coder (CPC) credential from the American Academy of Professional Coders (AAPC) is one of the most recognized certifications for those involved in medical coding and billing, covering ICD-10, CPT, and HCPCS codes. Other important certifications include the Certified Coding Specialist (CCS) from AHIMA, which focuses on coding for healthcare facilities, and the Certified in Healthcare Compliance (CHC) from the Health Care Compliance Association (HCCA), which emphasizes compliance with regulatory standards. Additionally, professionals may pursue the Certified in Risk Adjustment (CRA) certification, which focuses on risk adjustment coding, and the Certified Fraud Examiner (CFE) credential to specialize in fraud detection and prevention. These certifications equip claims and billing staff with the necessary knowledge and skills to accurately process claims, prevent fraud, and ensure regulatory compliance within the Medicare Advantage system.

There are requirements to run these Medicare Advantage plans. Staff are required to be trained and certified to ensure proper coding and billing. There are THOUSANDS of these plans across the country, and the vast majority of them aren't doing what these guys did.

So it's either fraud or gross incompetence. And in either case, it doesn't need an apologist trying to brush it all under the rug.

[Velvet]

So given everything you said, Joecooool, how did such a huge oversight (mismanagement) what ever you want to call it, happen?

[golfing eagles]

There are many people here that are "experts" on health care issues. There are not many agreeing with you.

Certified claims and billing staff within Medicare Advantage (MA) plans are crucial to ensuring that claims are processed accurately, in compliance with CMS regulations, and with proper documentation. Their primary responsibility is to submit and process claims by reviewing patient records to ensure that submitted claims align with diagnoses and procedures. They must verify the patient's eligibility for Medicare benefits and ensure proper coding and documentation for accurate reimbursement. These professionals are also responsible for medical coding, which is the conversion of healthcare diagnoses, procedures, medical services, and equipment into standardized codes, such as ICD-10 for diagnoses, CPT for procedures, and HCPCS for supplies. Accurate coding is essential for proper billing and reimbursement, as errors can lead to overpayment, underpayment, or potential fraud.

A key aspect of the job is managing risk adjustment, which involves assigning appropriate codes based on the health status of beneficiaries. Medicare Advantage plans rely on risk adjustment models, such as HCC (Hierarchical Condition Categories), to adjust payments according to the health conditions of beneficiaries. Claims and billing staff must ensure that the diagnoses submitted align with these models and that the documentation accurately supports the codes used. Additionally, fraud prevention is a critical responsibility, with billing staff trained to identify and prevent issues like upcoding, unbundling, and falsifying patient information. Medicare Advantage plans are held to strict fraud and abuse laws, and staff must be vigilant in ensuring compliance.

Claims and billing staff are also involved in audits and reporting, particularly in Risk Adjustment Data Validation (RADV) audits, where CMS ensures that submitted diagnoses are substantiated by medical records. Maintaining compliance with Medicare regulations (42 CFR Part 422), HIPAA privacy rules, and ongoing fraud detection efforts is essential. Regular reporting and participation in audits help ensure that the claims process remains transparent and accurate.

To ensure competency, claims and billing professionals must hold certifications that demonstrate their expertise. The Certified Professional Coder (CPC) credential from the American Academy of Professional Coders (AAPC) is one of the most recognized certifications for those involved in medical coding and billing, covering ICD-10, CPT, and HCPCS codes. Other important certifications include the Certified Coding Specialist (CCS) from AHIMA, which focuses on coding for healthcare facilities, and the Certified in Healthcare Compliance (CHC) from the Health Care Compliance Association (HCCA), which emphasizes compliance with regulatory standards. Additionally, professionals may pursue the Certified in Risk Adjustment (CRA) certification, which focuses on risk adjustment coding, and the Certified Fraud Examiner (CFE) credential to specialize in fraud detection and prevention. These certifications equip claims and billing staff with the necessary knowledge and skills to accurately process claims, prevent fraud, and ensure regulatory compliance within the Medicare Advantage system.

There are requirements to run these Medicare Advantage plans. Staff are required to be trained and certified to ensure proper coding and billing. There are THOUSANDS of these plans across the country, and the vast majority of them aren't doing what these guys did.

So it's either fraud or gross incompetence. And in either case, it doesn't need an apologist trying to brush it all under the rug.

I'll address the first and last sentences, it's obvious you googled, copied and pasted everything in between.

First) They probably disagree because they are NOT experts (except at google), and certainly don't have anywhere near my level of expertise

Last) I am not apologizing for anything since I have nothing to do with it. I am explaining and educating those who are not familiar with health care management. (And also ROFLing at those that paste something they googled and consider themselves knowledgeable)

[golfing eagles]

So given everything you said, Joecooool, how did such a huge oversight (mismanagement) what ever you want to call it, happen?

Give him a few minutes, he'll need to google that

[Topspinmo]

Give him a few minutes, he'll need to google that

Don’t doctors practices hire people to do paperwork/coding and insurance? And if work for company on salary contract don’t company hire people to do insurance/coding collecting? If not then it’s either the doctor or company mis-coding. Plenty examples especially in Florida over year’s of practice’s and doctors being prosecuted for Medicare fraud far less money, why should this practice be any different. Intentionally or not still millions dollars and want get out of paying it back by filing bankruptcy?

[golfing eagles]

Don’t doctors practices hire people to do paperwork/coding and insurance? And if work for company on salary contract don’t company hire people to do insurance/coding collecting? If not then it’s either the doctor or company mis-coding. Plenty examples especially in Florida over year’s of practice’s and doctors being prosecuted for Medicare fraud far less money, why should this practice be any different. Intentionally or not still millions dollars and want get out of paying it back by filing bankruptcy?

There are various methods for coding. The first is "point of service"--the provider codes the visit at the same time he generates the progress note. The drawback is that the provider needs to be familiar with CPT coding. TVH does not use that method, primarily because they are not paid by CPT code. Medicare Advantage plans capitate payments by diagnostic complexity and number of patients, which is quite different from traditional Medicare.

Another method if you are large enough is to have professional coders that work for you and evaluate the documentation and assign a CPT code---again, not relevant to Advantage plans.

Many medium size practices simply outsource billing and coding to a third party, usually for about 8% of the billing.

The mess TVH finds itself in is not CPT coding (although that would apply to the specialty clinics), but with the use or misuse of ICDM-10 codes, which have a lot of ambiguity and room for interpretation. Now, were the providers stretching the limitations of the coding definitions? Maybe, but I doubt that since as salaried employees they have nothing to gain. At some higher level was the coding tweaked or even falsified? I doubt it but anything is possible. Most like they simply used an aggressive coding philosophy that CMS decided was wrong. And they don't "get out of it" by declaring bankruptcy, they declare bankruptcy because they can't pay it back.

[Risuli]

I'll address the first and last sentences, it's obvious you googled, copied and pasted everything in between.

First)...

Last) I am not apologizing for anything since I have nothing to do with it. I am explaining and educating those who are not familiar with health care management. (And also ROFLing at those that paste something they googled and consider themselves knowledgeable)

In my opinion, the Last still stands as a valid question of either fraud or gross incompetence whether googled or not. If a simple billing error can cause your hospital to spiral into bankruptcy it would seem that proper management would have procedures in place to assure such errors are found, reported and eliminated well before your entire financial base is undermined. Again, just my opinion.

[BrianL99]

Last) I am not apologizing for anything since I have nothing to do with it. I am explaining and educating those who are not familiar with health care management. (And also ROFLing at those that paste something they googled and consider themselves knowledgeable)

It was not a direct "Google search", I looked.

It was AI. There are a number of clues, for those familiar with AI phrasing and logic.

[biker1]

I am still looking for some context. Specifically, they apparently overbilled by $360MM but over how many years was that? Also, of the revenue they brought in over those number of years, what percentage is $360MM?

In my opinion, the Last still stands as a valid question of either fraud or gross incompetence whether googled or not. If a simple billing error can cause your hospital to spiral into bankruptcy it would seem that proper management would have procedures in place to assure such errors are found, reported and eliminated well before your entire financial base is undermined. Again, just my opinion.

[golfing eagles]

It was not a direct "Google search", I looked.

It was AI. There are a number of clues, for those familiar with AI phrasing and logic.

same difference in this context

[Joecooool]

same difference in this context

What are you on about? You can't dispute what I put up so you want to just say it was googled? Even if it was, and it wasn't, who cares? It's still the facts, and those facts you can not dispute.

This company had paid certified professionals overcharge Medicare to the tune of $360M. In ANY book, that is fraud or gross incompetence.

[golfing eagles]

What are you on about? You can't dispute what I put up so you want to just say it was googled? Even if it was, and it wasn't, who cares? It's still the facts, and those facts you can not dispute.

This company had paid certified professionals overcharge Medicare to the tune of $360M. In ANY book, that is fraud or gross incompetence.

You’re still wrong, in ANY book. And you’re claiming those middle 4 paragraphs weren’t google or AI? Sorry, but the grammar, vocabulary and syntax in that post was way, way more sophisticated than anything else you’ve posted. No sale.

[JustSomeGuy]

Wrong, wrong and even more WRONG.

They did not believe there were "overcharges", therefore they did not exceed their expected revenue. And the "number of visits" is irrelevant with MA plans. I don't understand why this concept is so difficult to grasp, their budget was based on the LEGITIMATE expectation of revenue based on their number of patients and diagnostic mix, with outside consultants indicating that their coding was OK. There is nothing "extra". There is no slush fund or secret account. Nobody got hundreds of millions. There is no charge of fraud and no investigation because it is NOT NEEDED. Apparently, they have agreed to a settlement of what CMS considers a mistake in coding.

I trust you have much more experience in this than the rest of us but just saying wrong, wrong, wrong is not proof you are right.

The bankruptcy filing says: An internal investigation, supported by Goodwin Procter and FTI Consulting, revealed that a retrospective chart review program initiated around 2020 was inconsistent with Medicare guidelines.

We agree they have a budget each year. When setting their budget after this change, say for 2021, they must have planned for almost twice the income per claim or they exceeded budget by a tremendous amount. They had been open since 2012 so they had a good history to forecast from. Those seeing the "New" budget knew they somehow were able to double their income per patient with no other action except a change in billing practice from the previous 8 years.

Also stated in the filing is the fact that: "The program resulted in the submission of unsupported Hierarchical Condition Category (HCC) codes, which improperly inflated patient Risk Adjustment Factor (RAF) scores and, consequently, the capitated payments TVH received from Medicare Advantage plans." So the observation made that I was responding to - "

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing. A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing."

Does not match this situation where they actually took the same visit say for obesity and upgraded it to morbid obesity, increasing risk factor and increasing their payment. Or they up coded asthma to COPD. They were not changing one visit as noted above as two, which would not impact the risk score and is not listed in the bankruptcy filing documents.

As far as the last part of my statement you said was wrong. The developer owns 61% of Villages health, Villages health is an "asset light" organization. They lease everything (equipment and clinics) and own little. They have little debt, except the repayment of 320 million. Their main asset is their workforce. (from the bankruptcy files themselves, available on line) In 13 weeks the bankruptcy budget shows they loss 5,000,000 plus with two months rent (1,100,000 each) not included for some reason. This loss was evidently covered by the excess billing that is no longer happening. How will the new company continue to fund the same staff with the loss of 64,000 million in revenue per year (320 million divided by 5)?

Those are the issues you do not address. Someone deliberately started a new billing process (which caused CenterWell to immediately pull out of a non binding agreement to buy last summer when they saw it) in 2020. Was this billing change intentionally improper? CenterWell knew it was improper. How is the new buyer after the bankruptcy, going to continue to employ the same people if the only asset they have is the workforce and if they need to cut costs by $64,000,000 per year (no one has the money hidden anywhere, correct?)? They can't sell assets and lease them back to reduce costs.

FYI, the developer will get 60% of the 39 Million if the sale and the bankruptcy goes through. Taxpayers lose 320,000,000. Patients will see cuts in employees. If not, then the $320,000,000 was not used to cover day to day business costs. It was a was taken out of the business. CenterWell is not going to lose 64 million a year. If they do not need to cut costs then the 320 million was take as profit or some other non-recurring payment that can just end when the improper billing ends.

[BrianL99]

FYI, the developer will get 60% of the 39 Million if the sale and the bankruptcy goes through. Taxpayers lose 320,000,000.



How is the Developer going to end up with $24M? Typically, the Medicare claw-back would not be discharged in Bankruptcy. At a minimum, Medicare would be a priority debt and would get money from the sale, before anyone else does.

[Rainger99]

I trust you have much more experience in this than the rest of us but just saying wrong, wrong, wrong is not proof you are right.

The bankruptcy filing says: I An internal investigation, supported by Goodwin Procter and FTI Consulting, revealed that a retrospective chart review program initiated around 2020 was inconsistent with Medicare guidelines.

We agree they have a budget each year. When setting their budget after this change, say for 2021, they must have planned for almost twice the income per claim or they exceeded budget by a tremendous amount. They had been open since 2012 so they had a good history to forecast from. Those seeing the "New" budget knew they somehow were able to double their income per patient with no other action except a change in billing practice from the previous 8 years.

Also stated in the filing is the fact that: "The program resulted in the submission of unsupported Hierarchical Condition Category (HCC) codes, which improperly inflated patient Risk Adjustment Factor (RAF) scores and, consequently, the capitated payments TVH received from Medicare Advantage plans." So the observation made that I was responding to - "

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing. A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing."

Does not match this situation where they actually took the same visit say for obesity and upgraded it to morbid obesity, increasing risk factor and increasing their payment. Or they up coded asthma to COPD. They were not changing one visit as noted above as two, which would not impact the risk score and is not listed in the bankruptcy filing documents.

As far as the last part of my statement you said was wrong. The developer owns 61% of Villages health, Villages health is an "asset light" organization. They lease everything (equipment and clinics) and own little. They have little debt, except the repayment of 320 million. Their main asset is their workforce. (from the bankruptcy files themselves, available on line) In 13 weeks the bankruptcy budget shows they loss 5,000,000 plus with two months rent (1,100,000 each) not included for some reason. This loss was evidently covered by the excess billing that is no longer happening. How will the new company continue to fund the same staff with the loss of 64,000 million in revenue per year (320 million divided by 5)?

Those are the issues you do not address. Someone deliberately started a new billing process (which caused CenterWell to immediately pull out of a non binding agreement to buy last summer when they saw it) in 2020. Was this billing change intentionally improper? CenterWell knew it was improper. How is the new buyer after the bankruptcy, going to continue to employ the same people if the only asset they have is the workforce and if they need to cut costs by $64,000,000 per year (no one has the money hidden anywhere, correct?)? They can't sell assets and lease them back to reduce costs.

FYI, the developer will get 60% of the 39 Million if the sale and the bankruptcy goes through. Taxpayers lose 320,000,000. Patients will see cuts in employees. If not, then the $320,000,000 was not used to cover day to day business costs. It was a was taken out of the business. CenterWell is not going to lose 64 million a year. If they do not need to cut costs then the 320 million was take as profit or some other non-recurring payment that can just end when the improper billing ends.

Valid questions. I hope we get answers.

I currently have UHC Advantage so I go to TVH but I am seriously considering switching to Medicare.

How easy is it to find doctors within the Villages that are not part of TVH? I would prefer not having to drive to Leesburg, Ocala, etc.

[tophcfa]

This whole thing is a very interesting real life business case study. Speculation abound. At this point no one, not on the inside, really knows if this is an innocent mistake, total incompetence, our intentional fraud. The original question from the first post in this thread, “where did all the money go”, is a valid question. Generally speaking, the money could have gone into three broad categories, or a combination there of.

1) Invested wisely back into hard assets necessary to support a growing long term business.
2) Used to both retain and attract talented employees necessary to service a rapidly growing and health care needy senior population.
3) Diverted away from the he business to benefit the controlling principles.

Bases on the available assets, relative to liabilities (many being owed back to Medicare for overpayments and associated penalties), listed in the bankruptcy filing, it’s pretty clear the money didn’t go into option #1. It’s difficult to say where the money went between options #2 and 3? Here is hoping, for the long term best interest of all Villagers needing quality local health care, the money went the path of option #3. If the money was truly spent mostly on option #2, that’s not a good thing, as that money won’t be available in the future, and a drain of quality talent could be in the near future.

As previously noted in post #37 of this thread, the bigger picture here isn’t about blame for what has happened, it’s about the availability, going forward, of enough quality health care to meet the needs of a a very rapidly growing 55+ senior citizen retirement community that already has a highly stressed health care system. This is not only extremely important for all of us Villagers extremely important health care needs, but also the value of our Villages homes. Let’s not all bury our heads in the sand and lose track of the much bigger picture. This event casts a very dark cloud over the future of health care in our community.

[Rainger99]

The developer owns 61% of Villages health, Villages health is an "asset light" organization. They lease everything (equipment and clinics) and own little.

Is that true? TVH does not own the buildings but instead pays rent? Does anyone know who owns the buildings?

[LuvtheVillages]

Is that true? TVH does not own the buildings but instead pays rent? Does anyone know who owns the buildings?

It is well known that The Developer retains ownership of all the commercial properties, and changes significant rent to the businesses that occupy them. That would include the medical clinics.

[golfing eagles]

I trust you have much more experience in this than the rest of us but just saying wrong, wrong, wrong is not proof you are right.

The bankruptcy filing says: An internal investigation, supported by Goodwin Procter and FTI Consulting, revealed that a retrospective chart review program initiated around 2020 was inconsistent with Medicare guidelines.

We agree they have a budget each year. When setting their budget after this change, say for 2021, they must have planned for almost twice the income per claim or they exceeded budget by a tremendous amount. They had been open since 2012 so they had a good history to forecast from. Those seeing the "New" budget knew they somehow were able to double their income per patient with no other action except a change in billing practice from the previous 8 years.

Also stated in the filing is the fact that: "The program resulted in the submission of unsupported Hierarchical Condition Category (HCC) codes, which improperly inflated patient Risk Adjustment Factor (RAF) scores and, consequently, the capitated payments TVH received from Medicare Advantage plans." So the observation made that I was responding to - "

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing. A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing."

Does not match this situation where they actually took the same visit say for obesity and upgraded it to morbid obesity, increasing risk factor and increasing their payment. Or they up coded asthma to COPD. They were not changing one visit as noted above as two, which would not impact the risk score and is not listed in the bankruptcy filing documents.

As far as the last part of my statement you said was wrong. The developer owns 61% of Villages health, Villages health is an "asset light" organization. They lease everything (equipment and clinics) and own little. They have little debt, except the repayment of 320 million. Their main asset is their workforce. (from the bankruptcy files themselves, available on line) In 13 weeks the bankruptcy budget shows they loss 5,000,000 plus with two months rent (1,100,000 each) not included for some reason. This loss was evidently covered by the excess billing that is no longer happening. How will the new company continue to fund the same staff with the loss of 64,000 million in revenue per year (320 million divided by 5)?

Those are the issues you do not address. Someone deliberately started a new billing process (which caused CenterWell to immediately pull out of a non binding agreement to buy last summer when they saw it) in 2020. Was this billing change intentionally improper? CenterWell knew it was improper. How is the new buyer after the bankruptcy, going to continue to employ the same people if the only asset they have is the workforce and if they need to cut costs by $64,000,000 per year (no one has the money hidden anywhere, correct?)? They can't sell assets and lease them back to reduce costs.

FYI, the developer will get 60% of the 39 Million if the sale and the bankruptcy goes through. Taxpayers lose 320,000,000. Patients will see cuts in employees. If not, then the $320,000,000 was not used to cover day to day business costs. It was a was taken out of the business. CenterWell is not going to lose 64 million a year. If they do not need to cut costs then the 320 million was take as profit or some other non-recurring payment that can just end when the improper billing ends.

You are assuming that coding/billing somehow "changed" in 2020. The statement is ONLY that a retrospective review started looking at billing from 2020 to the present, it does not address 2012-2020. If the same billing and coding practices were in place from 2012 to 2020, your whole premise falls apart. NO adjustment in budget. No doubling the revenue. Just business as usual.

Now here's a concept I haven't considered: Many posters are considering the $361 M as "extra" and want to know where the money went. What if (hypothetical) they only broke even and without the "overpayments" they would have been in $361M of debt, ie: bankrupt a long time ago?????

[BrianL99]

It is well known that The Developer retains ownership of all the commercial properties, and changes significant rent to the businesses that occupy them. That would include the medical clinics.

What should they charge? Insignificant rent?

[Rainger99]

What should they charge? Insignificant rent?

It appears that the developer is charging rent to himself.
I would love to listen in to those “negotiations.”

I would think that TVH would get the “family discount” from the developer.

When my family comes and visits for a week, I don’t charge them a penny. And I am not a billionaire.

[BrianL99]

It appears that the developer is charging rent to himself.
I would love to listen in to those “negotiations.”

I would think that TVH would get the “family discount” from the developer.

.

That's not how business works.

The "Developer" consists of 100's of corporations and entities.

[Snowbirdtobe]

I started out this thread with the question where did all the money go? If you are a patient at TVH and the money was paid to keep the lights on expect dark buildings. If the money was used to fund lavish leaseholder improvements at Brownwood you should be fine unless the developer raises the 1,100,000 per month rent on the centers. I hate Brownwood and changed providers because St. Lukes was sending me to Brownwood for appointments. Moving out of the Brownwood care center should reduce the rent. Maybe that will be enough.

[tophcfa]

Now here's a concept I haven't considered: Many posters are considering the $361 M as "extra" and want to know where the money went. What if (hypothetical) they only broke even and without the "overpayments" they would have been in $361M of debt, ie: bankrupt a long time ago?????

Thanks Doc, there’s the bigger picture I’ve been trying to get folks to focus on. If that’s the case, what does that say about the future of health care in the fastest growing senior citizen community on the entire planet? People need to stop worrying about the past and contemplate the future availability of quality health care in the Villages! This unfortunate event most certainly doesn’t make the future look more positive.

[CoachKandSportsguy]

Thanks Doc, there’s the bigger picture I’ve been trying to get folks to focus on. If that’s the case, what does that say about the future of health care in the fastest growing senior citizen community on the entire planet? People need to stop worrying about the past and contemplate the future availability of quality health care in the Villages! This unfortunate event most certainly doesn’t make the future look more positive.

What tophcfa is highlighting is that

1) medicare is a very low reimbursement payment program. . most doctors and hospital systems can't survive with all the CMS requirements on just medicare reimbursements alone. That is why CMS has an additional reimbursement for improved outcomes, separate from individual encounter reimbursements. retirees have less opportunity for improved outcomes

2) most non retirement area hospitals have a mix of higher private pay insurance which is primarily employer sourced insurance, which pays a higher rate to offset the medicare rate to break even or not lose money.

3) So to stay financially solvent, taking only medicare isn't sustainable. . . upcoding with MA makes elderly patients financially viable. . . keep that in mind. .

So the problem with rapid growth of housing for long lived Medicare members, ie, the villages, can easily and quickly outstrip the hospital capacity without also planning and building simultaneously hospital capacity. This would fall on the developer, which he may or not make as a close secondary priority. .

So let's say the developer did keep up building hospital beds in the proper ratio, which health care system would lease out and operate out of the buildings if the primary reimbursement is medicare? and what's the probability that CMS will be able to pay for the reduced improved outcome potential? especially if one wants to reduce the federal deficit without]/b] increasing taxes?. . . .

the whole US health care system is a financial conundrum/dilemma/enigma/paradox, which currently has no solution on the horizon. . [b] its a damn can being kicked down the road. .

best to stay healthy and realize that there are limits to everything, there are no unlimited sources of money

[Caymus]

What tophcfa is highlighting is that

1) medicare is a very low reimbursement payment program. . most doctors and hospital systems can't survive with all the CMS requirements on just medicare reimbursements alone. That is why CMS has an additional reimbursement for improved outcomes, separate from individual encounter reimbursements. retirees have less opportunity for improved outcomes




Is Medicaid even less?

[LuvtheVillages]

Is Medicaid even less?

Yes, Medicaid is even less. That's why some doctors and clinics refuse to see, or limit, the Medicaid patients they accept. That's why long-term care homes that are mostly Medicaid residents have a reputation of being dirty and poorly staffed.

[drducat]

Key Assumptions
Patient Load Context: The 55,000 Medicare patient load refers to unique patients served annually, likely in a hospital or large healthcare system, as this aligns with the scale of the patient volume.
Revenue Basis: Revenue is derived from Medicare reimbursements, which vary by service type (e.g., inpatient, outpatient, physician services) and geographic location. I’ll use national averages for Medicare expenditures per beneficiary.
Profit Margins: Profit margins depend on operating costs, which include labor, supplies, and administrative expenses. Margins for Medicare patients are typically lower than for commercial payers due to lower reimbursement rates.
Data Sources: I’ll use data from the Centers for Medicare & Medicaid Services (CMS) and other healthcare financial reports, such as those from the American Hospital Association (AHA) and KFF, to estimate revenue and costs.
Geographic Variation: Medicare reimbursement rates vary by state, but I’ll use national averages for simplicity unless otherwise specified.
Service Mix: The patient load includes a mix of inpatient, outpatient, and physician services, typical for a hospital or integrated health system.
Estimating Revenue
Medicare Spending per Beneficiary
According to CMS data, Medicare spending per beneficiary in 2020 ranged from $8,726 (Vermont) to $13,652 (Florida), with a national average of approximately $10,000–$12,000 per beneficiary annually, depending on the year and service mix.
For 2023, total Medicare spending was $1,029.8 billion for approximately 65 million beneficiaries, yielding an average of about $15,843 per beneficiary ($1,029.8 billion ÷ 65 million). This figure includes inpatient hospital stays, outpatient services, physician services, and prescription drugs.
Adjusting for inflation and cost trends, I’ll use a conservative estimate of $14,000 per Medicare beneficiary for 2025, accounting for a mix of traditional Medicare and Medicare Advantage patients.
Revenue Calculation
For 55,000 Medicare patients:
\[
\text{Revenue} = 55,000 \times \$14,000 = \$770,000,000
\]

Estimated Annual Revenue: Approximately $770 million.
Revenue Breakdown by Service Type
Hospital Expenditures: In 2023, hospital expenditures accounted for 37% of Medicare spending. For $770 million in total revenue, this translates to roughly $285 million for hospital services (inpatient and outpatient).
Physician and Clinical Services: These accounted for 25% of Medicare spending, or about $192.5 million.
Prescription Drugs: These accounted for 14% of Medicare spending, or about $107.8 million.
Other Services: The remaining 24% (e.g., home health, skilled nursing) contributes approximately $184.7 million.
This breakdown assumes the patient load includes a typical mix of services. If the organization specializes (e.g., only outpatient care), the revenue distribution would shift.
Estimating Profit
Operating Costs
Hospital Costs: According to Definitive Healthcare, the average hospital operating expense in 2022 was $230.5 million for an average net patient revenue of $223.7 million, suggesting expenses often exceed or closely match revenue.
Medicare Underpayment: The AHA reports that in 2023, Medicare reimbursed hospitals at 83 cents for every dollar spent, resulting in a 17% underpayment rate. For $285 million in hospital revenue, this implies costs of approximately:
\[
\text{Costs} = \frac{\$285,000,000}{0.83} \approx \$343,373,494
\]

Thus, hospital services alone could result in a loss of about $58.4 million annually for Medicare patients.
Physician and Other Services: Physician services and outpatient care may have slightly better margins, but Medicare reimbursements still typically fall short of costs. Assuming a similar 17% underpayment rate across all services for simplicity:
\[
\text{Total Costs} = \frac{\$770,000,000}{0.83} \approx \$927,710,843
\]

Total Operating Costs: Approximately $928 million.
Profit Calculation
Net Operating Margin:
\[
\text{Profit} = \text{Revenue} - \text{Costs} = \$770,000,000 - \$927,710,843 \approx -\$157,710,843
\]

Estimated Annual Profit (Loss): A loss of approximately $157.7 million.
Adjusting for Real-World Margins
Hospital Margins: KFF reports that hospital operating margins in 2023 averaged 5.2% for all payers but were lower for hospitals with high Medicare patient shares (e.g., 3.1% for rural hospitals).
Medicare-Specific Margins: Medicare patients typically yield negative or near-zero margins due to underpayment. For-profit hospitals may achieve slightly positive margins (e.g., 0.3% for 340B program drugs), but nonprofit and public hospitals often face losses.
Alternative Scenario: If the organization optimizes costs (e.g., through efficient staffing or participation in programs like 340B), it might reduce the loss. For example, assuming a 5% operating margin on $770 million:
\[
\text{Profit} = \$770,000,000 \times 0.05 = \$38,500,000
\]

However, achieving a positive margin with Medicare patients alone is challenging without commercial payer revenue to offset losses.
Key Factors Affecting Revenue and Profit
Payer Mix: Hospitals with a higher proportion of commercial payers (who pay 254% of Medicare rates on average) can offset Medicare losses. A facility serving only Medicare patients is likely to operate at a loss.
Medicare Advantage (MA): MA plans, which cover about half of Medicare beneficiaries, often have lower reimbursement rates and stricter utilization controls (e.g., prior authorization), reducing revenue and increasing administrative costs.
Geographic Variation: Revenue per patient varies significantly (e.g., $13,652 in Florida vs. $8,726 in Vermont in 2020). Higher-cost regions may yield more revenue but also face higher operating costs.
Service Intensity: Patients with chronic conditions or higher acuity (e.g., heart failure, diabetes) increase costs due to longer stays and more intensive care.
340B Program: Participation in the 340B drug discount program can boost profits for outpatient drug administration, with estimated profits of $1.9 billion across all 340B hospitals in 2016 for Medicare Part B drugs.
Limitations
Data Gaps: The exact service mix, facility type, and geographic location are unspecified, so national averages may not reflect local realities.
Cost Variability: Operating costs vary widely based on labor markets, facility size, and efficiency. The 17% underpayment rate is an aggregate estimate and may not apply uniformly.
Medicare Advantage Impact: MA plans’ lower reimbursements and administrative burdens could reduce revenue and margins further than estimated.
Time Lag: Data from 2023 and earlier may not fully reflect 2025 reimbursement rates or cost trends.
Final Answer
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.

[BrianL99]

Key Assumptions
Patient Load Context: The 55,000 Medicare patient load refers to unique patients served annually, likely in a hospital or large healthcare system, as this aligns with the scale of the patient volume.


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.

According to this AI analysis, the Developer is the dumbest person on earth, for thinking he could make money in the Healthcare business, in The Villages.

It's simply amazing that someone so dumb, was able to amass a fortune that exceeds $4 BILLION dollars.

[CoachKandSportsguy]

According to this AI analysis, the Developer is the dumbest person on earth, for thinking he could make money in the Healthcare business, in The Villages.

It's simply amazing that someone so dumb, was able to amass a fortune that exceeds $4 BILLION dollars.

or he could afford the loss leader as a special marketing draw to the housing development side, which would be not unreasonable. . . given the arrogance of the hiring the puppets and using political ties to get favorable rulings in the FL gubmint, finding ways to upcode for more money is not an unreasonable stretch of belief in one's total control of the area. . .

seen many very successful business owners believe they can control way more than they actually can. .

[drducat]

According to this AI analysis, the Developer is the dumbest person on earth, for thinking he could make money in the Healthcare business, in The Villages.

It's simply amazing that someone so dumb, was able to amass a fortune that exceeds $4 BILLION dollars.

They didn't run this...the health biz has its own CEO.

[JustSomeGuy]

You are assuming that coding/billing somehow "changed" in 2020. The statement is ONLY that a retrospective review started looking at billing from 2020 to the present, it does not address 2012-2020. If the same billing and coding practices were in place from 2012 to 2020, your whole premise falls apart. NO adjustment in budget. No doubling the revenue. Just business as usual.

Now here's a concept I haven't considered: Many posters are considering the $361 M as "extra" and want to know where the money went. What if (hypothetical) they only broke even and without the "overpayments" they would have been in $361M of debt, ie: bankrupt a long time ago?????

I read the bankruptcy documents and did not assume. They clearly say:

"1. An internal investigation, supported by Goodwin Procter and FTI Consulting, revealed that a retrospective chart review program initiated around 2020 was inconsistent with Medicare guidelines.
2. The program resulted in the submission of unsupported Hierarchical Condition Category (HCC) codes, which improperly inflated patient Risk Adjustment Factor (RAF) scores and, consequently, the capitated payments TVH received from Medicare Advantage plans"

Initiated, in my opinion means started. Started around 2020. That program, initiated in 2020 "resulted in the submission of unsupported Hierarchical" coding.... and so on. The chart review program initiated around 2020 also caught the attention of the buyer and caused them to pull out. I can't find an assumption. So nothing falls apart. We do know that the Chart review led to the 320 million in question. Those funds were not invested in physical assets that can now be sold or identified or they would be listed as such in the filing.

[Stu from NYC]

We sure live in interesting times

[BrianL99]

They didn't run this...the health biz has its own CEO.

So the Real Estate Developer went into the Health Care business and hired someone to manage the health care operation?

Hmmmm .... do you think he hired someone who knew about banking, to run his banking operation?

[golfing eagles]

I read the bankruptcy documents and did not assume. They clearly say:

"1. An internal investigation, supported by Goodwin Procter and FTI Consulting, revealed that a retrospective chart review program initiated around 2020 was inconsistent with Medicare guidelines.
2. The program resulted in the submission of unsupported Hierarchical Condition Category (HCC) codes, which improperly inflated patient Risk Adjustment Factor (RAF) scores and, consequently, the capitated payments TVH received from Medicare Advantage plans"

Initiated, in my opinion means started. Started around 2020. That program, initiated in 2020 "resulted in the submission of unsupported Hierarchical" coding.... and so on. The chart review program initiated around 2020 also caught the attention of the buyer and caused them to pull out. I can't find an assumption. So nothing falls apart. We do know that the Chart review led to the 320 million in question. Those funds were not invested in physical assets that can now be sold or identified or they would be listed as such in the filing.

I guess I didn't express the reason you are wrong clearly enough, let's try again:

I, too, read the filing, and yes INITIATED IN 2020. That means not reviewed 2012-2020. Your initial premise was that TVH should have seen a "doubling" of revenue based on the "windfall" from miscoding when budgeting. But that assumes that the "miscoding" began in 2020 and resulted in a huge revenue increase. But it may have been going on all along, so there would be NO INCREASE EXPECTED when budgeting. Clear now?????

[CoachKandSportsguy]

I guess I didn't express the reason you are wrong clearly enough, let's try again:

I, too, read the filing, and yes INITIATED IN 2020. That means not reviewed 2012-2020. Your initial premise was that TVH should have seen a "doubling" of revenue based on the "windfall" from miscoding when budgeting. But that assumes that the "miscoding" began in 2020 and resulted in a huge revenue increase. But it may have been going on all along, so there would be NO INCREASE EXPECTED when budgeting. Clear now?????

totally agree with GE!
In fact, that is why they are using the "been the accepted practice internally" as their defense. ("it's not a lie if you believe it", George Costanza in the episode "The Beard" )
Consistent with the size of the practice and the number of audited MA reimbursements entities in the past.
Totally consistent with the developers attitude w/respect to the home owners opinions, and his answer being "give them cheap beer" and everything will be fine.
Totally consistent with past success of political control enabling bolder behavior towards grifting. .

but then again, I am jaded from seeing many unethical behaviors in business and elsewhere. . where money and perceived power is involved. .