Villages Health Bankruptcy

[Rainger99]

The Philosophy Club had a meeting today and the topic was "Understanding The Bankruptcy of The Villages Healthcare System.”

The speaker said that most of the papers filed in the case are online.

The link is below.

The Villages Health System, LLC (https://cases.stretto.com/thevillageshealth/)

Perhaps some of the lawyers or doctors on TOTV can go over the files and explain them to us.

[Snowbirdtobe]

I’ll bet there are 100 lawyers listed as being involved in the case and none of them could explain it.
How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?

[jimbomaybe]

I’ll bet there are 100 lawyers listed as being involved in the case and none of them could explain it.
How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?
Even an automobile that is considered a total loss after an accident has some value for parts , the price is relative to what is salvageable

[Caymus]

I’ll bet there are 100 lawyers listed as being involved in the case and none of them could explain it.
How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?

Has value if they are not "buying" the debt/liabilities.

[ScottFenstermaker]

The Philosophy Club had a meeting today and the topic was "Understanding The Bankruptcy of The Villages Healthcare System.”

The speaker said that most of the papers filed in the case are online.

The link is below.

The Villages Health System, LLC (https://cases.stretto.com/thevillageshealth/)

Perhaps some of the lawyers or doctors on TOTV can go over the files and explain them to us.
The developer-owned Daily Sun has access to all the details since TVHS is 70% owned by the developer. However, the Daily Sun first published a rose-tinted description of the bankruptcy and has since buried the story.

[Bill14564]

The Philosophy Club had a meeting today and the topic was "Understanding The Bankruptcy of The Villages Healthcare System.”

The speaker said that most of the papers filed in the case are online.

The link is below.

The Villages Health System, LLC (https://cases.stretto.com/thevillageshealth/)

Perhaps some of the lawyers or doctors on TOTV can go over the files and explain them to us.

There are two other threads here (https://www.talkofthevillages.com/forums/medical-health-discussion-94/uhc-under-federal-investigation-medicare-fraud-360223/?highlight=bankrupt) and here (https://www.talkofthevillages.com/forums/villages-florida-general-discussion-73/villages-health-where-did-all-money-go-359950/?highlight=bankrupt) that discuss this. What specific question do you have that is not covered in one of those?

From a patient's standpoint, the xxxxxxxx health care centers are trying to stay open and have been (or are in the process of being) acquired. Ideally, there will be few changes for the patient. Realistically, the new owners have their way of doing business which could have some effects.

[tophcfa]

I’m sure it would have been interesting to be a fly on the wall at the August 6th creditors meeting. Hopefully the bankruptcy court is prioritizing the best interest of TVH patients throughout this process?

[CoachKandSportsguy]

I’m sure it would have been interesting to be a fly on the wall at the August 6th creditors meeting. Hopefully the bankruptcy court is prioritizing the best interest of TVH patients throughout this process?

seems like that would be a first, but lets hope so!

The value is in the assets, physical mostly. . the bankruptcy is in the debt portion being bigger than the asset portion. . .

TVH didn't hide anything, they just found a payment loophole and exploited it until they got caught. . The buyers saw an extremely profitable company and was looking to either buy it, get in on the profitability, ie competitive intelligence, or bankrupt it and buy the physical assets as distressed property.

having worked in M&A along time ago, many interested buyers are also looking for competitive intelligence, even after signing an NDA. . for their own interests. .

[blueash]

There are two other threads here (https://www.talkofthevillages.com/forums/medical-health-discussion-94/uhc-under-federal-investigation-medicare-fraud-360223/?highlight=bankrupt) and here (https://www.talkofthevillages.com/forums/villages-florida-general-discussion-73/villages-health-where-did-all-money-go-359950/?highlight=bankrupt) that discuss this. What specific question do you have that is not covered in one of those?

From a patient's standpoint, the hospital is trying to stay open and has been (or is in the process of being) acquired. Ideally, there will be few changes for the patient. Realistically, the new owners have their way of doing business which could have some effects.

There is no hospital now and never has been one in the Villages Health care system. Nor is the hospital that used to be the Villages Hospital and now is UF Health Spanish Plaines undergoing any reorganization or sale or "trying to stay open". This is how misinformation and rumors spread.

[Rainger99]

What specific question do you have that is not covered in one of those?


There was a lot of discussion on those threads but few answers.

My specific questions are:

The speaker mentioned a loan to TVH paying 12% interest. The lender is PMA Lender, LLC.

Does anyone know anything about PMA?

The speak also said that UHC alleged that TVH had a “record of corporate misbehavior.”

Does anyone know what this refers to?

[CoachKandSportsguy]

The speak also said that UHC alleged that TVH had a “record of corporate misbehavior.”

Does anyone know what this refers to?

legal tactic, but potentially true, given the perceived omnipotence of the TV corporate empire abilities to control the local and state legal and political system with crony mafiaism. .

I wouldn't discount it, given my experiences with corporate america, and the quest for power/control and money. .

a monopoly is the first place winning trophy of any and every capitalistic venture. .

[Rainger99]

This is a list of all of the filed and scheduled claims.

The largest one is from the The Villages of Lake-Sumter, Inc., and is for $15,00,000. I didn't see a claim by the government for $361,000,000 and the claim from Humana is $0 and the claim by UHC is only $187.36.

The Villages Health System, LLC (https://cases.stretto.com/thevillageshealth/claims/)

[OrangeBlossomBaby]

There is no hospital now and never has been one in the Villages Health care system. Nor is the hospital that used to be the Villages Hospital and now is UF Health Spanish Plaines undergoing any reorganization or sale or "trying to stay open". This is how misinformation and rumors spread.

He edited the word - it was what's commonly known as a brain-fart. Up here in the "old" section, the hospital and TVH are right next to each other, and it's easy for our fingers to type out one when we mean the other, because we see them as connected and by extension, synonymous. Even though they're obviously not the same thing.

Meanwhile - the doctors themselves have little to do with, and no say in the administrative events of the company they work for. They're not share-holders or even subcontractors. They're employees. So I'm thinking we will likely not see any change with regards to patient care, unless those doctors leave the company and move on to other groups or practices.

Referrals and billing procedures might change. Costs might go up. Co-pays might change. But the annual physical performed by your physician is likely to be exactly as it was the last time you had one.

[BrianL99]

seems like that would be a first, but lets hope so!

The value is in the assets, physical mostly. . the bankruptcy is in the debt portion being bigger than the asset portion. . .



I think the "value" isn't related to physical assets, as I don't think the TVH has much. As I understand it, they didn't own real estate and medical equipment is usually leased these days.

The "value" (if any) is in 2 things, in my opinion: Staffing & Subscribers (& perhaps some intellectual property (names, logos, software, domains, agreements, etc.).

[Rainger99]

I think the "value" isn't related to physical assets, as I don't think the TVH has much. As I understand it, they didn't own real estate and medical equipment is usually leased these days.

The "value" (if any) is in 2 things, in my opinion: Staffing & Subscribers (& perhaps some intellectual property (names, logos, software, domains, agreements, etc.).

This is what they stated in their bankruptcy filing.

TVH’s assets consist primarily of its top-tier workforce of medical providers and
dedicated support staff, and their relationships to the patients. TVH is a party to long-term leases for each of its Care Centers, and TVH leases much of the significant medical equipment used in the day-to-day operation of the Care Centers.

Is their workforce top-tier???

[golfing eagles]

This is what they stated in their bankruptcy filing.

TVH’s assets consist primarily of its top-tier workforce of medical providers and
dedicated support staff, and their relationships to the patients. TVH is a party to long-term leases for each of its Care Centers, and TVH leases much of the significant medical equipment used in the day-to-day operation of the Care Centers.

Is their workforce top-tier???

Like any workforce, some are and some are not.

[Rainger99]

This is the best explanation that I have seen for the coding discrepancies. It is from the TVH's bankruptcy filing.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that Centers for Medicare and Medicaid Services (CMS) pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.

I thought that the insurance companies receive larger payments - not the TVH.

Article on Risk Adjustment Factor (RAF) score fraud.

Understanding Risk Adjustment Factor (RAF) Score Fraud and How to Get a Reward for Reporting It - Daniel J. Ocasio Whistleblower Law Group (https://whistleblowerlawfirms.com/2023/06/understanding-risk-adjustment-factor-raf-score-fraud-and-how-to-get-a-reward-for-reporting-it/)

[Club A]

8/15/2025 Presentation "Understanding the Bankruptcy of The Villages Health System LLC"

There was a capacity crowd at Lake Miona Rec Center. After the presentation, when polled, 100% of attendees thought it was fraud not mistake!

Because TOTV does not permit links, please go to NextDoor to find the links to the presentation.

[drducat]

So doctors are complicit in putting down diagnosis of things such as 4th stage kidney failure if your blood test shows increase of BUN value which can be off due to dehydration etc etc


Those can be a one off report and means nothing unless it continues...if your chart shows a list of problems that you are not being treated for or have no knowledge of them you could be a victim.

[OrangeBlossomBaby]

So doctors are complicit in putting down diagnosis of things such as 4th stage kidney failure if your blood test shows increase of BUN value which can be off due to dehydration etc etc


Those can be a one off report and means nothing unless it continues...if your chart shows a list of problems that you are not being treated for or have no knowledge of them you could be a victim.

If that's what happened, then yeah doctors would be complicit. But that's not what happened. Doctors don't do billing, they don't input billing codes. I've explained this before...I'll try it again.

Let's say you have a regular annual checkup, and the doctor asks how you've been feeling. You say you're fine, except your bunion's been hurting lately. The doctor says he can give you a referral to a podiatrist if you want, you say thanks, but my bunion pads are still working, it's probably just the humidity lately.

The doctor inputs the code for the annual physical. He inputs the code for the discussion about your bunion (because it's important to know that there's a history of it, in case you do need a referral, he can tell the podiatrist you've had this problem since at least xyz date and are treating it with bunion pads).

He sends the documentation through the system, and now it's the billing department's turn to deal with it.

The billing department puts in the billing code for the annual physical.
They also put a billing code for a podiatry consultation, because record-keeping is important.

You only pay your co-pay, which is probably 0 since it was all part of your physical exam.
But the insurance company sees the code for the podiatry consultation, and sends your doctor's office a check for $197 instead of $143, because an annual physical plus podiatry consultation pays out $197.

But here's the thing - there are 7 different billing codes that COULD be input, for a brief moment's worth of discussion with a doctor during an annual physical about your bunion. The one your doctor's billing department chose was the wrong one. The one they were supposed to choose should have resulted in a $146 payment, not a $197 payment (and not the bare-bones $143 payment either).

But this is the billing code they've been using for years whenever any of the thousands of patients they have discusses a bunion during an annual physical, and up until now, no one's said "hey wait a minute - why is everyone using this code? Surely some patients have different bunion conversations during their annual physicals?"

So that's essentially what happened.

[Bill14564]

8/15/2025 Presentation "Understanding the Bankruptcy of The Villages Health System LLC"

There was a capacity crowd at Lake Miona Rec Center. After the presentation, when polled, 100% of attendees thought it was fraud not mistake!

Because TOTV does not permit links, please go to NextDoor to find the links to the presentation.

Good thing our justice system doesn't run on polls of people who have just attended a one hour meeting.

ToTV does allow links and some of us do not have NextDoor accounts.l

[golfing eagles]

So doctors are complicit in putting down diagnosis of things such as 4th stage kidney failure if your blood test shows increase of BUN value which can be off due to dehydration etc etc


Those can be a one off report and means nothing unless it continues...if your chart shows a list of problems that you are not being treated for or have no knowledge of them you could be a victim.

Bad example. Stage 4 CKD (Chronic Kidney Disease) is defined as a GFR (Glomerular Filtration Rate) of 15-30. An increase in BUN (Blood Urea Nitrogen) does not qualify by a long shot, so if "doctors" were using that diagnosis in that situation, it would be fraud, but I highly doubt that is the case. And I doubt the "poll" mentioned above, since there is NOTHING that 100% of Villagers will ever agree upon.

[golfing eagles]

If that's what happened, then yeah doctors would be complicit. But that's not what happened. Doctors don't do billing, they don't input billing codes. I've explained this before...I'll try it again.

Let's say you have a regular annual checkup, and the doctor asks how you've been feeling. You say you're fine, except your bunion's been hurting lately. The doctor says he can give you a referral to a podiatrist if you want, you say thanks, but my bunion pads are still working, it's probably just the humidity lately.

The doctor inputs the code for the annual physical. He inputs the code for the discussion about your bunion (because it's important to know that there's a history of it, in case you do need a referral, he can tell the podiatrist you've had this problem since at least xyz date and are treating it with bunion pads).

He sends the documentation through the system, and now it's the billing department's turn to deal with it.

The billing department puts in the billing code for the annual physical.
They also put a billing code for a podiatry consultation, because record-keeping is important.

You only pay your co-pay, which is probably 0 since it was all part of your physical exam.
But the insurance company sees the code for the podiatry consultation, and sends your doctor's office a check for $197 instead of $143, because an annual physical plus podiatry consultation pays out $197.

But here's the thing - there are 7 different billing codes that COULD be input, for a brief moment's worth of discussion with a doctor during an annual physical about your bunion. The one your doctor's billing department chose was the wrong one. The one they were supposed to choose should have resulted in a $146 payment, not a $197 payment (and not the bare-bones $143 payment either).

But this is the billing code they've been using for years whenever any of the thousands of patients they have discusses a bunion during an annual physical, and up until now, no one's said "hey wait a minute - why is everyone using this code? Surely some patients have different bunion conversations during their annual physicals?"

So that's essentially what happened.

Exactly!!!

So, what are the chances that will convince "100%" of the attendees at that meeting?

[drducat]

Bad example. Stage 4 CKD (Chronic Kidney Disease) is defined as a GFR (Glomerular Filtration Rate) of 15-30. An increase in BUN (Blood Urea Nitrogen) does not qualify by a long shot, so if "doctors" were using that diagnosis in that situation, it would be fraud, but I highly doubt that is the case. And I doubt the "poll" mentioned above, since there is NOTHING that 100% of Villagers will ever agree upon.

So dehydration also shows low GFR values...either way both are true . Needs to be watched not put down as diagnosed as.....

[Rainger99]

So that's essentially what happened.

Do you have any facts to support this?

[drducat]

Bad example. Stage 4 CKD (Chronic Kidney Disease) is defined as a GFR (Glomerular Filtration Rate) of 15-30. An increase in BUN (Blood Urea Nitrogen) does not qualify by a long shot, so if "doctors" were using that diagnosis in that situation, it would be fraud, but I highly doubt that is the case. And I doubt the "poll" mentioned above, since there is NOTHING that 100% of Villagers will ever agree upon.

So dehydration also sho

[Aces4]

[QUOTE=OrangeBlossomBaby;2454027]If that's what happened, then yeah doctors would be complicit. But that's not what happened. Doctors don't do billing, they don't input billing codes. I've explained this before...I'll try it again.

Let's say you have a regular annual checkup, and the doctor asks how you've been feeling. You say you're fine, except your bunion's been hurting lately. The doctor says he can give you a referral to a podiatrist if you want, you say thanks, but my bunion pads are still working, it's probably just the humidity lately.

The doctor inputs the code for the annual physical. He inputs the code for the discussion about your bunion (because it's important to know that there's a history of it, in case you do need a referral, he can tell the podiatrist you've had this problem since at least xyz date and are treating it with bunion pads).

He sends the documentation through the system, and now it's the billing department's turn to deal with it.

The billing department puts in the billing code for the annual physical.
They also put a billing code for a podiatry consultation, because record-keeping is important.
************************************************** ************************************************** ***
If that's the explanation, I think it's bogus that the billing dept is responsible for "record-keeping". That is medical records responsibility and why would the billing department be ready to charge for a discussion between Dr. and patient which included no extra service. Sloppy, sloppy, sloppy or profit, profit, profit IMHO. Is a patient required to walk into their appt and inform the Dr certain subjects are off limit lest the patient be billed for it?

[kingofbeer]

8/15/2025 Presentation "Understanding the Bankruptcy of The Villages Health System LLC"

There was a capacity crowd at Lake Miona Rec Center. After the presentation, when polled, 100% of attendees thought it was fraud not mistake!

Because TOTV does not permit links, please go to NextDoor to find the links to the presentation.
Who was the presenter for this show?

[asianthree]

Do you have any facts to support this?

Anyone who spends the usual 2 weeks of training in any medical facility, has a working knowledge of what box to check for whatever treatment they specifically performed.

iPads screen pops up to clarify bloodwork, BP and so forth.

Then charting is briefly read by NP, PA, Physician, who continues with the visit, checks boxes, adds notes, add information discussed. Notes for follow up, change or continue current meds, specific tests, or speciality appointments.
Then sign off. Entire document is printed for patient to walk out the door.

All the procedures are coded, and usually billed by outside companies. I haven’t in house coded billing for over 15 years.

Unless you are living in a town of 1,000 with one doctor, and his wife is the nurse, and biller. Which is rare. Physicians & hospitals went away from onsite billing, sometimes used the dreaded out of US billing.

I have to ask don’t you go over the paperwork? Because if you don’t involve yourself with your medical visits, and the follow-up notes, check you insurance statements, maybe a family member could help. You would then understand what was billed and is it correct.

[golfing eagles]

So dehydration also shows low GFR values...either way both are true . Needs to be watched not put down as diagnosed as.....

Dehydration will primarily affect BUN and to a lesser extent creatinine. You can also look at the BUN/cr ratio---- >40 is pre-renal (dehydration), <20 with an elevated creatinine is usually renal in origin

[Rainger99]

Currently, the Villages Health takes Advantage plans from UnitedHealthcare, Humana, and Florida Blue.

Has there been any statement from UHC or Florida Blue that they will stay with TVH - especially if Humana owns it?

[Altavia]

Do you have any facts to support this?

As someone who spent 45 years around hospitals and medical system diagnostics, Asianthree, OBB and GE are speaking reality.

[BrianL99]

This is the best explanation that I have seen for the coding discrepancies. It is from the TVH's bankruptcy filing.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that Centers for Medicare and Medicaid Services (CMS) pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.

I thought that the insurance companies receive larger payments - not the TVH.

Article on Risk Adjustment Factor (RAF) score fraud.

Understanding Risk Adjustment Factor (RAF) Score Fraud and How to Get a Reward for Reporting It - Daniel J. Ocasio Whistleblower Law Group (https://whistleblowerlawfirms.com/2023/06/understanding-risk-adjustment-factor-raf-score-fraud-and-how-to-get-a-reward-for-reporting-it/)

You only pay your co-pay, which is probably 0 since it was all part of your physical exam.
But the insurance company sees the code for the podiatry consultation, and sends your doctor's office a check for $197 instead of $143, because an annual physical plus podiatry consultation pays out $197.

But here's the thing - there are 7 different billing codes that COULD be input, for a brief moment's worth of discussion with a doctor during an annual physical about your bunion. The one your doctor's billing department chose was the wrong one. The one they were supposed to choose should have resulted in a $146 payment, not a $197 payment (and not the bare-bones $143 payment either).

I thought with Medicare Advantage Plans, the Payments from Medicare were essentially as Rainger laid out. A "monthly payment per patient", based on their level of need.

I thought traditional Medicare (NON Advantage Plans) made payments per what OBB laid out.

It can't be both ways. Either they pay a "lump sum" per month, based on a Patient's level of complication or they pay individually, for specific procedures.

It sounds to me, like two separate and distinct Medicare fraud/over-billing/mis-coding. In one instance, the patient's general health/complications are inflated for a larger monthly payment.

In the other instance, the patient's individual procedures are miscoded or exaggerated.

Which is it?

[Rainger99]

As someone who spent 45 years around hospitals and medical system diagnostics, Asianthree, OBB and GE are speaking reality.

Those aren’t facts.

Post a link to the bankruptcy filings that support their statements.

[spinner1001]

I thought with Medicare Advantage Plans, the Payments from Medicare were essentially as Rainger laid out. A "monthly payment per patient", based on their level of need.

No. CMS also pays MA plans incentive bonuses when plans surpass certain patient health benchmarks.

Medicare Advantage Quality Bonus Payments Will Total at Least $12.7 Billion in 2025 | KFF (https://www.kff.org/medicare/issue-brief/medicare-advantage-quality-bonus-payments/)

Bonus payments to a MA plan can be millions of dollars.

CMS pays a MA plan periodic risk-based rates plus potentially bonuses. Then the plan pays the MA clinic (provider) based on whatever contract terms the plan and clinic negotiate.

[BrianL99]

I thought with Medicare Advantage Plans, the Payments from Medicare were essentially as Rainger laid out. A "monthly payment per patient", based on their level of need.

I thought traditional Medicare (NON Advantage Plans) made payments per what OBB laid out.

Which is it?

No. CMS also pays MA plans incentive bonuses when plans surpass certain patient health benchmarks.

Medicare Advantage Quality Bonus Payments Will Total at Least $12.7 Billion in 2025 | KFF (https://www.kff.org/medicare/issue-brief/medicare-advantage-quality-bonus-payments/)

Bonus payments to a MA plan can be millions of dollars.

CMS pays a MA plan periodic risk-based rates plus potentially bonuses. Then the plan pays the MA clinic (provider) based on whatever contract terms the plan and clinic negotiate.

That wasn't the question.

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

I doubt it can be both ways. OBB's scenario of the "bunion story" presumes Medicare is invoiced for and pays, for each individual visit and/or procedure. I don't think that's the case with Medicare Advantage Plans. I think Medicare simply pays a "lump sum" per patient, depending on the patient's overall health condition. ("Bonuses" are irrelevant to the question).

[Zenmama18]

I’m sure it would have been interesting to be a fly on the wall at the August 6th creditors meeting. Hopefully the bankruptcy court is prioritizing the best interest of TVH patients throughout this process?

Probably not, more likely to prioritize the best interests of the creditors.

[rsmurano]

For me, The biggest issue with TVH is that they only take Medicare advantage plans which I think is a huge mistake.
Also, there can never be a monopoly in the health care system in TV. There are more drs outside of the TVH system so people have many choices on who to see. Also, no dr is dedicated to 1 company. There is so much turnover in drs around here, no company could state they will have this specialist tomorrow. My wife, before she was on Medicare, was going to drs in the TVH system that disappeared before her next 6 month visit so she was constantly having to re-establish with a new dr. Now being on a Medicare supplement plan g plan, she has seen the same dr at other facilities.

[golfing eagles]

For me, The biggest issue with TVH is that they only take Medicare advantage plans which I think is a huge mistake.
Also, there can never be a monopoly in the health care system in TV. There are more drs outside of the TVH system so people have many choices on who to see. Also, no dr is dedicated to 1 company. There is so much turnover in drs around here, no company could state they will have this specialist tomorrow. My wife, before she was on Medicare, was going to drs in the TVH system that disappeared before her next 6 month visit so she was constantly having to re-establish with a new dr. Now being on a Medicare supplement plan g plan, she has seen the same dr at other facilities.

I think you would find the high turnover rate is due to the fact that there are just as many, if not more, physicians at TVH that are near the end of their career than those at the beginning of theirs. Young doctors tend to want to be near urban areas and suburbs with children for playmates for theirs. There is little attraction for a young family in a 55+ retirement community. Plus, the salaries are higher elsewhere.

[maggie1]

legal tactic, but potentially true, given the perceived omnipotence of the TV corporate empire abilities to control the local and state legal and political system with crony mafiaism. .

I wouldn't discount it, given my experiences with corporate america, and the quest for power/control and money. .

a monopoly is the first place winning trophy of any and every capitalistic venture. .

I guess I needed to have chosen a different profession to understand all of this, but I didn't. What I do understand (I think) is that the Village Health System is on the hook for $300,000,000 in over-billing to United Health. So, will someone please answer me this:

1. Where did that money end up, and who profited from it?

2. With that amount of fraud involved, who was responsible for it, and why haven't criminal charges been filed?

3. Will United Health still be our primary insurance provider, or will they bow out?

If somebody doesn't get some time (prison) out of this, then my faith in the justice system will have eroded even further.

[BlueStarAirlines]

How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?

UnitedHealth has their own Medicare billing issues with the Government that dwarfs the Villages Health issue.

RemovePaywall | Free online paywall remover (https://www.removepaywall.com/search?url=https://www.nytimes.com/2025/07/24/health/unitedhealth-medicare-justice-department.html)

[spinner1001]

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

Pay who? The MA plan or clinic?

Regardless, neither described by Rainger and OBB is necessarily true for MA. If the MA financial model were simple, there would be less disagreement and confusion.

[Biskopski]

It wasn't losses. They overbilled Medicare and got caught from the government DOGE audit.

[BrianL99]

That wasn't the question.

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

.

Pay who? The MA plan or clinic?

Regardless, neither described by Rainger and OBB is necessarily true for MA. If the MA financial model were simple, there would be less disagreement and confusion.

Based on the fact that Medicare is saying TVH "over-billed" them, that must mean that Medicare pays TVH directly (which surprises me). It sounds like the Insurance carrier is just a "middle man", providing management of the patient/doctor relationship.

With 100's of posts on the subject, it seems someone must actually know the formula for how TVH gets it's revenue and from whom. Again, Rainger & OBB's characterizations of the payment structure/arrangement are diametrically opposed ... two separate and distinct arrangements.

Does Medicare pay TVH a specific amount per patient, regardless of what or how many procedures they have (adjusted only for bonuses and/or "complexity" level of their conditions) ....

Or ... does Medicare pay TVH per visit and/or per procedure, as OBB claimed in the bunion story.

& how does the insurance company get paid, if they're not billing Medicare directly?

Call me crazy, but if no one understands how billing and payments actually work, how does anyone have an opinion on who's getting pork'd and how?

[golfing eagles]

It wasn't losses. They overbilled Medicare and got caught from the government DOGE audit.

That statement couldn't be more wrong! They MAY HAVE "overbilled", depending on which interpretation of ICDM-10 diagnostic criteria is applied. This was discovered during negotiations for being acquired by Humana, and self-reported to CMS BEFORE DOGE EVEN EXISTED, BEFORE THE ELECTION AS WELL.

[Dgodin]

Why buy in? 55,000 patients.$$$

[Bill14564]

Based on the fact that Medicare is saying TVH "over-billed" them, that must mean that Medicare pays TVH directly (which surprises me). It sounds like the Insurance carrier is just a "middle man", providing management of the patient/doctor relationship.

With 100's of posts on the subject, it seems someone must actually know the formula for how TVH gets it's revenue and from whom. Again, Rainger & OBB's characterizations of the payment structure/arrangement are diametrically opposed ... two separate and distinct arrangements.

Does Medicare pay TVH a specific amount per patient, regardless of what or how many procedures they have (adjusted only for bonuses and/or "complexity" level of their conditions) ....

Or ... does Medicare pay TVH per visit and/or per procedure, as OBB claimed in the bunion story.

& how does the insurance company get paid, if they're not billing Medicare directly?

Call me crazy, but if no one understands how billing and payments actually work, how does anyone have an opinion on who's getting pork'd and how?

From some very quick reading, here is one possibility:
- A Medicare Advantage (MA) plan receives a monthly amount ($1,000?) per patient regardless of any treatment
- The monthly amount is intended to be more than enough to cover costs which allows the MA plan to off additional services
- The provider sees patients and bills the MA plan for services provided
- If the services provided indicate the patient is sicker than average then the MA plan can bill Medicare extra for that patient
- The additional money paid by Medicare is passed through MA to the provider

- TVH may interact only with the MA plan
- TVH requests reimbursement through coding
- If the coding is within a "normal" range of services, the MA plan reimburses TVH from the monthly amount it receives for that patient
- If the coding is above normal (sicker patient) then MA requests additional funding from Medicare
- The additional funding is passed to the TVH

If it is later found that the "above-normal" coding was inaccurate then Medicare may choose to demand reimbursement. Since the coding was done by TVH and the additional funds were given to TVH it is logical that Medicare would approach TVH for any reimbursement.

Since TVH doesn't have $360M just sitting around to be used for reimbursement, it anticipates a serious problem and has filed for bankruptcy protection.

The above is certainly missing some details and nuances but it seems to be consistent with the description of the flow of funds with Advantage plans and what has been reported in various articles.

[OrangeBlossomBaby]

That wasn't the question.

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

I doubt it can be both ways. OBB's scenario of the "bunion story" presumes Medicare is invoiced for and pays, for each individual visit and/or procedure. I don't think that's the case with Medicare Advantage Plans. I think Medicare simply pays a "lump sum" per patient, depending on the patient's overall health condition. ("Bonuses" are irrelevant to the question).

If you want the answer to that, first consider the common sense answer, using a common hypothetical.

MA pays X dollars for patient John. Every month. No more, no less. And then John is found to have a brain tumor that is treatable with chemo, targeted radiation, months of physical and speech therapy, home health aids, and two months in rehab.

Who's gonna pay for all that? Or will John simply die because he can't afford it? Answer: Something ELSE is going to happen, besides MA simply paying out X dollars for patient John.

What is that something else? I don't know. But I'm confident it's something else.

[Rainger99]

I am still confused. I thought Medicare Advantage worked the following way:

For every patient enrolled in UHC, Medicare pays a certain amount to UHC. This is based on your RAF rating (Risk Adjustment Factor). RAF is based on your overall health.

The average score is 1.00 and assuming that the average payment is $1000, UHC would get $1000 a month for each patient with an RAF rating of 1. If a person has a score of .8, UHC would get $800 a month and if a person had an RAF score of 1.5, UHC would get $1500 a month.

I thought that if UHC provides less care than the amount that Medicare pays each month that UHC keeps that as profit. And if UHC provides more care than the amount that Medicare pays each month, UHC has to make up the difference.

This is from the bankruptcy filing.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that CMS pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who
have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.

In approximately August 2024, TVH became aware of a potential issue with respect
to its HCC guidance. At that time, TVH learned that it may have submitted HCC diagnosis codes that were not clinically supported or otherwise did not meet Medicare coding and payment guidance. For example, TVH engaged in a retrospective review program (in which patients’ medical histories were reviewed to identify instances in which TVH believed additional codes were supportable and could be added) that may not have been consistent with Medicare coding and payment guidance.

I think it means (but I am not sure) that if TVH assigned you a higher RAF rating, that TVH would get more per procedure so that TVH would have an incentive to assign people higher RAF scores. Do they get more procedure or do they usually have more procedures because they are in worse health?

I am not sure how this works with UHC. It seems that UHC would get more money each month also since their payment is based on RAF scores. If that is the case, does UHC owe Medicare a lot of money?

Is there someone that can explain this? A lawyer, a coder, a doctor?

Has anyone obtained their RAF score? I contacted UHC and they told me to contact TVH.

[Rainger99]

If you want the answer to that, first consider the common sense answer, using a common hypothetical.

MA pays X dollars for patient John. Every month. No more, no less. And then John is found to have a brain tumor that is treatable with chemo, targeted radiation, months of physical and speech therapy, home health aids, and two months in rehab.

Who's gonna pay for all that? Or will John simply die because he can't afford it? Answer: Something ELSE is going to happen, besides MA simply paying out X dollars for patient John.

What is that something else? I don't know. But I'm confident it's something else.

If a Medicare Advantage (MA) plan spends more on a particular patient than its capitation rate, the plan itself is responsible for covering the excess cost.

That is why UHC's profits fell 19% last year.

[OrangeBlossomBaby]

I think you would find the high turnover rate is due to the fact that there are just as many, if not more, physicians at TVH that are near the end of their career than those at the beginning of theirs. Young doctors tend to want to be near urban areas and suburbs with children for playmates for theirs. There is little attraction for a young family in a 55+ retirement community. Plus, the salaries are higher elsewhere.

Agreed. Thanks to the massive expansion of The Villages, there are fewer and fewer neighborhoods where young families can raise their children. Public schools are getting worse and worse while the Charter School is taking more and more children of lower-income employees of/at The Villages. Private schools are few and far between. Middleton is great, IF you work in the southern half of The Villages. But why would anyone want to commute an hour in each direction for a relatively low-paying job as a doctor, nurse, PA, receptionist, scheduler, phlebotomist, etc at TVH up in Spanish Springs?

TVH was awesome for years because it was relatively exclusive, and didn't need thousands of employees to care for tens of thousands of patients. That's all changed. It's become an enormous machine that has been pieced together with duct tape and zip-ties, and the only people who know how it's run, are getting ready to retire.

[OrangeBlossomBaby]

I am still confused. I thought Medicare Advantage worked the following way:

For every patient enrolled in UHC, Medicare pays a certain amount to UHC. This is based on your RAF rating (Risk Adjustment Factor). RAF is based on your overall health.

The average score is 1.00 and assuming that the average payment is $1000, UHC would get $1000 a month for each patient with an RAF rating of 1. If a person has a score of .8, UHC would get $800 a month and if a person had an RAF score of 1.5, UHC would get $1500 a month.

I thought that if UHC provides less care than the amount that Medicare pays each month that UHC keeps that as profit. And if UHC provides more care than the amount that Medicare pays each month, UHC has to make up the difference.

This is from the bankruptcy filing.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that CMS pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who
have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.

In approximately August 2024, TVH became aware of a potential issue with respect
to its HCC guidance. At that time, TVH learned that it may have submitted HCC diagnosis codes that were not clinically supported or otherwise did not meet Medicare coding and payment guidance. For example, TVH engaged in a retrospective review program (in which patients’ medical histories were reviewed to identify instances in which TVH believed additional codes were supportable and could be added) that may not have been consistent with Medicare coding and payment guidance.

I think it means (but I am not sure) that if TVH assigned you a higher RAF rating, that TVH would get more per procedure so that TVH would have an incentive to assign people higher RAF scores. Do they get more procedure or do they usually have more procedures because they are in worse health?

I am not sure how this works with UHC. It seems that UHC would get more money each month also since their payment is based on RAF scores. If that is the case, does UHC owe Medicare a lot of money?

Is there someone that can explain this? A lawyer, a coder, a doctor?

Has anyone obtained their RAF score? I contacted UHC and they told me to contact TVH.

That
Is
Not
What
Is
Happening.

I don't know how people can explain this to make it any more clear than has already been explained.

The "issue" with this incident of overpayment has to do with billing codes. Not RAF or PMPMs or guaranteed minimum monthly payments to the Health Center. It is specifically a billing code error.

Start there, and work your way back.

[tophcfa]

Agreed. Thanks to the massive expansion of The Villages, there are fewer and fewer neighborhoods where young families can raise their children. Public schools are getting worse and worse while the Charter School is taking more and more children of lower-income employees of/at The Villages. Private schools are few and far between. Middleton is great, IF you work in the southern half of The Villages. But why would anyone want to commute an hour in each direction for a relatively low-paying job as a doctor, nurse, PA, receptionist, scheduler, phlebotomist, etc at TVH up in Spanish Springs?

TVH was awesome for years because it was relatively exclusive, and didn't need thousands of employees to care for tens of thousands of patients. That's all changed. It's become an enormous machine that has been pieced together with duct tape and zip-ties, and the only people who know how it's run, are getting ready to retire.

In summary, the Villages has, and continues to, grow too fast relative to the necessary infrastructure and employment base needed to support the needs of a very large senior citizen population. It’s one thing when growth outpaces service jobs like irrigation repair or restaurant cooks and service providers, but it’s entirely another level of problem when growth outpaces the availability of quality healthcare. This whole unfortunate thing happening with The Villages Health is exposing a very serious problem for an aging population with greater health care needs than the general population.

[Rainger99]

The "issue" with this incident of overpayment has to do with billing codes. Not RAF or PMPMs or guaranteed minimum monthly payments to the Health Center. It is specifically a billing code error.

Start there, and work your way back.

You say that the issue has to do with billing codes - not RAF or PMPMs.

This is from the Villages Health bankruptcy filing. They are claiming that.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that Centers for Medicare and Medicaid Services (CMS) pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.

They are ones talking about PMPMs and RAF scores. In fact, I never heard of either term before yesterday.

Are you saying that the Villages Health lawyers are mistaken? That it wasn't about PMPMs or RAF scores?

[GWilliams]

I’ll bet there are 100 lawyers listed as being involved in the case and none of them could explain it.
How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?

They buy the loss to write off the profit=No taxes.

[biker1]

Do you know for a fact that the buyer will assume the loss? If they have a loss then they don't have a profit.

They buy the loss to write off the profit=No taxes.

[jojo]

Curious to know who the speaker was for the philosophy club?

[CoachKandSportsguy]

They buy the loss to write off the profit=No taxes.

possible, but in this case, buying the loss means buying the customers/physical assets. . . and the loss comes with the Medicare liability. . . if they buy the business without the Medicare liability, there is no loss, just customers and assets, assets which get revalued, and customers who start all over with billing codes and medical encounters.

usually in the purchase to use the loss, is an operating loss carry forward after a transaction has been completed. . . which I am not certain that will apply in this case, as its a continuing operating liability. . .

but i am not a tax lawyer, and don't even want to play one on TV

[Rainger99]

Curious to know who the speaker was for the philosophy club?


Steve Andelman

He said that he was not a lawyer or a doctor.

[ScottFenstermaker]

There have been a number of posts concerning the manner in which TVHS is paid by United Health and the other insurers for Mecicare Part C. Several of the posts are inaccurate or speculative. To get the facts (or at least TVHS's version of them), click here and read paragraph 27: https://cases.stretto.com/public/x458/13910/PLEADINGS/1391007032580000000204.pdf

To understand that paragraph, one must realize that TVHS is not paid by the Part C insurers for each service TVHS renders, which is the traditional Medicare Part C method. Instead, TVHS gets a monthly, per capita payment.

Warning: even after reading paragraph 27, you will not understand the calculation of the $361million claim of the US Government. That cannot be discerned on the basis of any of the filings in the bankruptcy case-- so far.

[jimjamuser]

In summary, the Villages has, and continues to, grow too fast relative to the necessary infrastructure and employment base needed to support the needs of a very large senior citizen population. It’s one thing when growth outpaces service jobs like irrigation repair or restaurant cooks and service providers, but it’s entirely another level of problem when growth outpaces the availability of quality healthcare. This whole unfortunate thing happening with The Villages Health is exposing a very serious problem for an aging population with greater health care needs than the general population.
Great summary. I have been in Florida since 1968 and there has been one consistent thing and that was CONSTANT change. I noticed it particularly in traffic and commuting. It seemed that the width and lanes of the roads NEVER caught up to the amount of traffic that they had to carry. It seems like the same analogy would apply to healthcare. The population growth overwhelms the healthcare systems.

[MplsPete]

\\\\\

[JMintzer]

If that's what happened, then yeah doctors would be complicit. But that's not what happened. Doctors don't do billing, they don't input billing codes. I've explained this before...I'll try it again.

Let's say you have a regular annual checkup, and the doctor asks how you've been feeling. You say you're fine, except your bunion's been hurting lately. The doctor says he can give you a referral to a podiatrist if you want, you say thanks, but my bunion pads are still working, it's probably just the humidity lately.

The doctor inputs the code for the annual physical. He inputs the code for the discussion about your bunion (because it's important to know that there's a history of it, in case you do need a referral, he can tell the podiatrist you've had this problem since at least xyz date and are treating it with bunion pads).

He sends the documentation through the system, and now it's the billing department's turn to deal with it.

The billing department puts in the billing code for the annual physical.
They also put a billing code for a podiatry consultation, because record-keeping is important.

You only pay your co-pay, which is probably 0 since it was all part of your physical exam.
But the insurance company sees the code for the podiatry consultation, and sends your doctor's office a check for $197 instead of $143, because an annual physical plus podiatry consultation pays out $197.

But here's the thing - there are 7 different billing codes that COULD be input, for a brief moment's worth of discussion with a doctor during an annual physical about your bunion. The one your doctor's billing department chose was the wrong one. The one they were supposed to choose should have resulted in a $146 payment, not a $197 payment (and not the bare-bones $143 payment either).

But this is the billing code they've been using for years whenever any of the thousands of patients they have discusses a bunion during an annual physical, and up until now, no one's said "hey wait a minute - why is everyone using this code? Surely some patients have different bunion conversations during their annual physicals?"

So that's essentially what happened.

Never, in my 40 years of practice, did any of my billing staff decide what to bill. I made that decision each and every time...

[asianthree]

Great summary. I have been in Florida since 1968 and there has been one consistent thing and that was CONSTANT change. I noticed it particularly in traffic and commuting. It seemed that the width and lanes of the roads NEVER caught up to the amount of traffic that they had to carry. It seems like the same analogy would apply to healthcare. The population growth overwhelms the healthcare systems.

Truthfully we have noticed the residents the farther south you go are far younger than northern areas. When one is in 40s 50s early 60s, healthcare issues isn’t top of their list. The older residents moved from the north, so equal numbers.

By the time the southern residents reach 80s and 90s when some may need multiple physicians and visits. The circle of life in the northern areas will have become younger. I see my dentist twice a year, and have a yearly visit with cardiology. Dermatologist said I wasted his time, come back in 3-5 years or if you find something off color.
Never used a primary care so one less waste of an hour.

[BrianL99]

The one your doctor's billing department chose was the wrong one. The one they were supposed to choose should have resulted in a $146 payment, not a $197 payment (and not the bare-bones $143 payment either).


The "issue" with this incident of overpayment has to do with billing codes. Not RAF or PMPMs or guaranteed minimum monthly payments to the Health Center. It is specifically a billing code error.

Start there, and work your way back.

I was told today, by someone who used to do this for a living, that your characterization of how it works, is incorrect for Medicare Advantage Plans.


If a Medicare Advantage (MA) plan spends more on a particular patient than its capitation rate, the plan itself is responsible for covering the excess cost.

That is why UHC's profits fell 19% last year.

You say that the issue has to do with billing codes - not RAF or PMPMs.

This is from the Villages Health bankruptcy filing. They are claiming that.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that Centers for Medicare and Medicaid Services (CMS) pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.

They are ones talking about PMPMs and RAF scores. In fact, I never heard of either term before yesterday.

Are you saying that the Villages Health lawyers are mistaken? That it wasn't about PMPMs or RAF scores?

That same person told me today, you are correct in the way Medicare Advantage Plans get paid. It's all about the patient's "score". Artificially "boosting" scores is how the Insurers/providers make more money.

The person I spoke with was convicted of Medicare Fraud and lost his medical license, so I suspect he knows what he's talking about.

[gldfin]

seems like that would be a first, but lets hope so!

The value is in the assets, physical mostly. . the bankruptcy is in the debt portion being bigger than the asset portion. . .

TVH didn't hide anything, they just found a payment loophole and exploited it until they got caught. . The buyers saw an extremely profitable company and was looking to either buy it, get in on the profitability, ie competitive intelligence, or bankrupt it and buy the physical assets as distressed property.

having worked in M&A along time ago, many interested buyers are also looking for competitive intelligence, even after signing an NDA. . for their own interests. .

How can you make a statement that they just found a payment loophole? Illegally billing incorrect billing codes is not a loophole, it is fraud no different than a collision center billing an insurance company for new original OEM parts and installing non OEM or used parts.thay is a general problem with society today, lack of accountability. Who pays for their overrbilling? Everyone who pays employment taxes.

[spinner1001]

Call me crazy, but if no one understands how billing and payments actually work, how does anyone have an opinion on who's getting pork'd and how?

That sums it up pretty concisely.

The public does not have TVH contracts to say how TVH finances actually work and many posts are mostly BS.

I subscribe to a specialized AI platform for deep research. I had it write a report on Medicare Advantage micro economics from CMS to MA plans to MA clinics. The document is long and dense for two reasons. The government's MA program is complicated and, second, for clinics, MA micro economics depend on their particular contracts with MA insurance plans. Contracts differ. If you have seen one contract, you have seen one contract.

Below is a link to the report on Medicare Advantage micro economics from CMS to clinics (providers). Again, it's long and dense. Happy reading. There will be a quiz next Friday.

Dropbox (https://www.dropbox.com/scl/fi/s2g3e6cgn8saqita2c0t9/The_Granular_Mechanics_of_Medicare_Advantage__Paye r_Provider_Economics_and_ACO_Contrasts.pdf?rlkey=d oeeuydhtqwenysiybckd6gxl&st=ss9mzydh&dl=0)

[CoachKandSportsguy]

How can you make a statement that they just found a payment loophole? Illegally billing incorrect billing codes is not a loophole, it is fraud no different than a collision center billing an insurance company for new original OEM parts and installing non OEM or used parts.thay is a general problem with society today, lack of accountability. Who pays for their overrbilling? Everyone who pays employment taxes.

ok, loophole is a colloquial term, and there are different interpretations.
I am in no way saying their loophole wasn't fraud, i have stated before that their audits were paid for to pass, but i suspect that it's the same up coding which others are using, until they get caught. .

There are always gray areas in accounting, and many keep trying the same scam years apart. If you go back to read some of my posts on the topic, you will see that I in no way find what they did not fraudulent. .

there are always ways to cheat, everyone who takes their profession seriously knows where the line exists. Most choose not to go over the line, some people like to get as close to it as they can, others get close and then without repercussions, keep going farther and end up over the line. Many are over the line until someone decides to actually penalize them. . until then, they feel great knowing that they think they have beaten the system.

I have seen it personally,

[Rainger99]

That sums it up pretty concisely.

The public does not have TVH contracts to say how TVH finances actually work and many posts are mostly BS.

I subscribe to a specialized AI platform for deep research. I had it write a report on Medicare Advantage micro economics from CMS to MA plans to MA clinics. The document is long and dense for two reasons. The government's MA program is complicated and, second, for clinics, MA micro economics depend on their particular contracts with MA insurance plans. Contracts differ. If you have seen one contract, you have seen one contract.

Below is a link to the report on Medicare Advantage micro economics from CMS to clinics (providers). Again, it's long and dense. Happy reading. There will be a quiz next Friday.

Dropbox (https://www.dropbox.com/scl/fi/s2g3e6cgn8saqita2c0t9/The_Granular_Mechanics_of_Medicare_Advantage__Paye r_Provider_Economics_and_ACO_Contrasts.pdf?rlkey=d oeeuydhtqwenysiybckd6gxl&st=ss9mzydh&dl=0)

The article is long and dense!

The more I look at this issue, the more confused I get. I started out thinking that Medicare pays Medicare Advantage a certain amount of money each month for each patient.

This is from the Medicare handbook.

When you join a Medicare Advantage Plan, Medicare pays a fixed amount for your
coverage each month to the private company offering your Medicare Advantage Plan.

And this is from another website.

Rather than directly covering care as needed, the federal government pays lump sum Medicare dollars, known as capitated payments, to these private insurers for each patient.

I thought that once Medicare makes the monthly payment to UCH, Medicare is out of the picture and Medicare Advantage is responsible for making any payments to the doctors or clinics.

That is why I can't figure out how Medicare is involved. They made their monthly payment to UHC and UHC had to pay for medical treatment submitted by TVH. If TVH was making mistakes in coding, UHC would be the victim - not Medicare.

However, after reading the TVH bankruptcy filing, it appears that the major issue was that the HCC codes were incorrect and this lead to higher RAF scores which in turn lead to higher payments from Medicare to UHC. But I still can't see how TVH benefited from that. Wouldn't the payment go directly to UHC (or Humana or Blue Cross)?

The goal seems to be to get as much money from Medicare and spend as little money on medical treatment.

There was an article in the NY Times on October 8, 2022, discussing how the MA insurers were being sued for adding additional illnesses to their patients' records. However, it said nothing about how doctors or clinics were benefiting from the HCC codes and RAF scores.

Perhaps there is something in the contracts between TVH and the MA insurers that would explain this. Hopefully, it will come out in the bankruptcy proceeding or the Villages Daily Sun.

[CoachKandSportsguy]

https://www.talkofthevillages.com/forums/2454376-post10.html

this post might explain how the changes in billing codes from line item to bundled changes the profitability of the physicians office, and if the coding update is missed or not adhered to, past billing practices which were outdated can result in lots of over billing. .

again, the management / auditing oversight was lacking in maintaining up to date coding as designated by CMS. .

I suspect that there will be a few more of these as well as future changes in medical services here in TV as a result of the medicare billing changes to reign increased longevity related medical costs. . sux to have a society who increased life spans, and then have the medical system effectively stop supporting them. . many medical practitioners will be fine with a mix Medicare and private pay balance, to keep the doctors solvent, but most retirees will not be. .

rock meet hard place. .

[BrianL99]

The goal seems to be to get as much money from Medicare and spend as little money on medical treatment.

There was an article in the NY Times on October 8, 2022, discussing how the MA insurers were being sued for adding additional illnesses to their patients' records. However, it said nothing about how doctors or clinics were benefiting from the HCC codes and RAF scores.

Perhaps there is something in the contracts between TVH and the MA insurers that would explain this. Hopefully, it will come out in the bankruptcy proceeding or the Villages Daily Sun.

This is strictly a guess. I have no 1st hand knowledge, but based on what I'm reading and hearing about this situation, this is my speculation (for whatever that's worth).

The only way that TVH can be responsible, is if they were billing Medicare, directly. Which means that TVH was the "provider" and not the insurance company. It seems like the arrangement between the Insurer & the Provider, is not what many presume it to be. The Insurer may only be responsible for providing management of the subscriber/provider relationship and supplying the over-riding financial backing for the Group Practice.

Sort of like the Insurance company is a "back-stop", that provides high-level oversight and protection from catastrophic losses.

...either that, or TVH is simply paying the Insurance company to use it's name and their business is essentially self-contained?

[ScottFenstermaker]

Meanwhile, the Daily Sun, which (because of its ownership by the Developer) could clarify all this stuff, continues to bury the story.

[BrianL99]

Meanwhile, the Daily Sun, which (because of its ownership by the Developer) could clarify all this stuff, continues to bury the story.

"Burying it" would presume they acknowledged it.

I don't know that they've even acknowledged it so far. Then again, I opened the Daily Sun only once since I came to TV and immediately tossed it in the circular file.

[OrangeBlossomBaby]

Never, in my 40 years of practice, did any of my billing staff decide what to bill. I made that decision each and every time...

You weren't an employee of a large health care organization. Doctors at TVH don't have their own billing staff. They are EMPLOYEES, this isn't a private practice and they're not contractors or sub-contractors or doctors who lease space in someone else's medical center.

The doctors input what they did and the diagnostic code that corresponds with it. The billing department matches the diagnostic code with a billing code (or multiple billing codes) and inputs that. If there's more than one billing code for a diagnostic code, or series of diagnostic codes, then the billing department decides which billing code is applied. The doctor has nothing to do with it at that point.

[Rainger99]

This is strictly a guess. I have no 1st hand knowledge, but based on what I'm reading and hearing about this situation, this is my speculation (for whatever that's worth).

The only way that TVH can be responsible, is if they were billing Medicare, directly. Which means that TVH was the "provider" and not the insurance company. It seems like the arrangement between the Insurer & the Provider, is not what many presume it to be. The Insurer may only be responsible for providing management of the subscriber/provider relationship and supplying the over-riding financial backing for the Group Practice.

Sort of like the Insurance company is a "back-stop", that provides high-level oversight and protection from catastrophic losses.

...either that, or TVH is simply paying the Insurance company to use it's name and their business is essentially self-contained?

I am surprised that no one - the Villages, the government, the Insurance Companies, the attorneys or anyone else has issued any kind of statement explaining how the over-billing happened.

Or that details have not leaked.

[Rainger99]

I am listening to the radio and I just heard an ad talking about the No UPCODE Act. Never heard of it until five minutes ago. It talks about risk adjustments and coding.

[blueash]

I will do my best to explain, my understanding, of how this works. Medicare (CMS) gives private carriers (UHC, Humana etc) an opportunity to cover patients who qualify for Medicare. Those carriers are paid a fixed amount per covered life to cover all costs, physicians, hospital, pharmacy, lab, etc.

The only adjustment comes if it turns out that the patients who enroll are sicker than the average Medicare aged patient. If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.

So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.

Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works. In the case of fee for service then the only way to increase payment is to bill for services at a higher level or complexity. I can tell you from my own EOBs that I see no evidence of that being the case. A routine exam is being billed with the correct codes, and illness visits are also being correctly billed as to complexity. I have seen no charges for services not done.

Lastly, entirely IMO, I do not believe any of this was fraud. Rather it is a quirk in the system where the doctor wants everything in the chart for completeness but that completeness makes the patient look sicker as most offices don't bother computer entering everything.

What is needed is a way to enter a concern, but to be able to note that it is not requiring management. There are so many of these that every patient has. A patch of dry skin, occasional headaches that have been for years, mild spring allergies, intermittent constipation. These kinds of things are true, real, and should be noted. But if there is not ongoing management, just living with it, the entry in the record becomes a problem as CMS cannot differentiate actively managed vs not managed.

[CoachKandSportsguy]

I will do my best to explain, my understanding, of how this works. Medicare (CMS) gives private carriers (UHC, Humana etc) an opportunity to cover patients who qualify for Medicare. Those carriers are paid a fixed amount per covered life to cover all costs, physicians, hospital, pharmacy, lab, etc.

The only adjustment comes if it turns out that the patients who enroll are sicker than the average Medicare aged patient. If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.

So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.

Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works. In the case of fee for service then the only way to increase payment is to bill for services at a higher level or complexity. I can tell you from my own EOBs that I see no evidence of that being the case. A routine exam is being billed with the correct codes, and illness visits are also being correctly billed as to complexity. I have seen no charges for services not done.

Lastly, entirely IMO, I do not believe any of this was fraud. Rather it is a quirk in the system where the doctor wants everything in the chart for completeness but that completeness makes the patient look sicker as most offices don't bother computer entering everything.

What is needed is a way to enter a concern, but to be able to note that it is not requiring management. There are so many of these that every patient has. A patch of dry skin, occasional headaches that have been for years, mild spring allergies, intermittent constipation. These kinds of things are true, real, and should be noted. But if there is not ongoing management, just living with it, the entry in the record becomes a problem as CMS cannot differentiate actively managed vs not managed.

Fact check: TRUE

However, one can go into their electronic medical records and make adjustments, if they are using EPIC.

When I questioned the doctor about the forever list, he said its there for reference of past medical history issues. . "OK", until you get to Medicare.

However, I am not yet on Medicare, and will convert at the end of this year. . when I have to then have a "Medicare" physical. .

One last point about physician services codes and billing codes:
In large systems, such as EPIC in large hospital systems, there is automation for many of the mundane and commonly used service codes to billing codes.

However, there is constant reviews and auditing methods to insure proper compliance. In physician only medical offices, which may be using small system electronic medical records, the process may be more manual than big hospital systems. . BUT they have a choice of partnering with a major hospital system and using their system as a separate instance. . .

My eye doctors' office uses the Mass general or brighams womens EPIC system, and their hospital payment system. . and am having a billing issue with them right now.

but we learn alot here on TOTV, with all the previous work experiences who have actual knowledge of the issue du jour

[golfing eagles]

Fact check: TRUE

However, one can go into their electronic medical records and make adjustments, if they are using EPIC.

When I questioned the doctor about the forever list, he said its there for reference of past medical history issues. . "OK", until you get to Medicare.

However, I am not yet on Medicare, and will convert at the end of this year. . when I have to then have a "Medicare" physical. .

One last point about physician services codes and billing codes:
In large systems, such as EPIC in large hospital systems, there is automation for many of the mundane and commonly used service codes to billing codes.

However, there is constant reviews and auditing methods to insure proper compliance. In physician only medical offices, which may be using small system electronic medical records, the process may be more manual than big hospital systems. . BUT they have a choice of partnering with a major hospital system and using their system as a separate instance. . .

My eye doctors' office uses the Mass general or brighams womens EPIC system, and their hospital payment system. . and am having a billing issue with them right now.

but we learn alot here on TOTV, with all the previous work experiences who have actual knowledge of the issue du jour

TVH does not use EPIC. I'm pretty sure their EMR comes from a minor league player.

[Rainger99]

If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.

So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.

Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works.

I thought that the extra money that goes to the insurance company stays with the insurance company but it is assumed that a person with a high RAF score will have more treatment than a person with a low RAF score. If a person has severe health problems, I expect that they see the doctor more frequently than the average person and that the treatment is more complicated.

I don't see how the provider ends up making extra because their monthly payment is increased for each patient in the plan. If TVH were diagnosing the patient to be in worse health than they were, UHC gets more money per patient, but I don't see how TVH benefits because the patient would not be getting the extra treatment. Unless the codes pay more depending on the RAF score?

For example, if a person in good health sees a doctor for a physical and the doctor gets $100, does the doctor get $150 for giving a physical to a person that is "supposed" to be in poor health?

Does anyone know if TVH gets captivated payments per patient?

For example, does TVH get $500 a month for a healthy person and $1000 a month for a sick person? I thought the monthly payments go to UHC - not to TVH - and UHC does its best to limit the amount of treatment that TVH gives its patients because the money that doesn't go to TVH stays with UHC.

The whole process seems to be a lot more complicated than it should be!

[golfing eagles]

The whole process seems to be a lot more complicated than it should be!

Out of hundreds of posts on this topic, most of them "uninformed" at best, that one is 100% true. :bigbow:

[Topspinmo]

legal tactic, but potentially true, given the perceived omnipotence of the TV corporate empire abilities to control the local and state legal and political system with crony mafiaism. .

I wouldn't discount it, given my experiences with corporate america, and the quest for power/control and money. .

a monopoly is the first place winning trophy of any and every capitalistic venture. .


This all my opinion from pass dealing and observations?

IMO UHC scruples practice has been investigated in pass and made sweet deal with VHC. Which also MY OPINION was bad deal based on past investigations. My question? VHC exclusively UHC insurance which billing codes I would think sent to UHC which should have raised flags when billing? But, when feds paid with no alarm bells going off everything seems good right?

IMO Now somebody ratted them out (because maybe they wasn’t getting enough action?) and now all sudden after years of raking in millions it’s now problem. Now they trying to bail with pocket change and sell out the headache they manufactured.

What I don’t understand why business would limit it customer base only allowing one insurance provider? I think we know why? ACA should have fixed insurance monopoly, but guess they had to read it to find out what was actually in it before they passed it?

This all my opinion cause don’t have clue or little clue what practice’s actually do when comes to record keeping and billing, cause if I want MY information in pass I have to pay for it while everybody else gets it for free. Besides, who questions bills unless you have to pay for it?

It also well know fact IMO that health care companies rack up tests, proscribe pills, and procedures to run up bill to stay in business or extra profit. Even dental industry does it with X-rays and the money maker deep cleaning. How do I know this? I been to 4 dentist in 10 years here in Florida. 3 out 4 demanded deep cleaning and X-rays when I just had both that less than 6 months form other dentist I ran from.

[Topspinmo]

Out of hundreds of posts on this topic, most of them "uninformed" at best, that one is 100% true. :bigbow:

Isn’t that why have forums? To post B—S we know nothing about to find out? otherwise why have forums if take questions out?

[drducat]

Your RAF score is calculated by your insurance provider. They use what your doctor puts down during your first yearly visit...it resets every year in Jan.

[Rainger99]

Your RAF score is calculated by your insurance provider. They use what your doctor puts down during your first yearly visit...it resets every year in Jan.

From my research, Medicare calculates it - not the insurance company.

I think Medicare calculates it on information from your health provider - and not from your insurance company.

[drducat]

Medicare Advantage organizations calculate the RAF score for their enrollees.
This is based on data from patient encounters, including diagnoses (ICD-10 codes) and demographic information.
The data is submitted to CMS (Centers for Medicare & Medicaid Services) for processing.

[Rainger99]

I am attaching the new ICD-10-CM Official Guidelines for Coding and Reporting that go into effect on October 1, 2025. It is 120 pages!

I am glad that I didn't go to medical school!

https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

[ScottFenstermaker]

Medicare lawyers are soliciting in The Villages. I wonder if TVHS doctors are starting to lawyer up. Click here: (The link works.)

federal-lawyer.com | 520: Web server is returning an unknown error (https://federal-lawyer.com/healthcare/the-villages/)

[golfing eagles]

I am attaching the new ICD-10-CM Official Guidelines for Coding and Reporting that go into effect on October 1, 2025. It is 120 pages!

I am glad that I didn't go to medical school!

https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

Only 120 pages? The last manual I handled was about 3-4 inches thick. Must be the abridged version

[Nucky]

Out of hundreds of posts on this topic, most of them "uninformed" at best, that one is 100% true. :bigbow:

Hello, my Friend. I've checked in several times on this particular thread, started reading through, and got discouraged, so I clicked off. Is there any possibility for old times' sake that you could wrap up the future status of my beloved healthcare, and is it possible that it will stay as it is? Hope you are doing well.

The rumors of my recent demise are incorrect. We sure did have a whole lot of fun on here in the old days. Did you ever collect your LOBSTER? :1rotfl::1rotfl::1rotfl:

[golfing eagles]

Hello, my Friend. I've checked in several times on this particular thread, started reading through, and got discouraged, so I clicked off. Is there any possibility for old times' sake that you could wrap up the future status of my beloved healthcare, and is it possible that it will stay as it is? Hope you are doing well.

The rumors of my recent demise are incorrect. We sure did have a whole lot of fun on here in the old days. Did you ever collect your LOBSTER? :1rotfl::1rotfl::1rotfl:

No, Barefoot has successfully welshed on our bet for almost 9 years now. And despite her home in Canada where cold water lobster abounds, I remain devoid of seafood :1rotfl::1rotfl::1rotfl:

I wish I could tell you the future of healthcare in TV, but I don't think anyone knows yet. I only know a few things that others don't, but very little and nothing that would indicate the future prospects for TVH. I do think that TVH will continue in one form or another, I doubt it will just close its doors on 50,000 patients. Right now it appears, but only from what others have posted on social media, that they need some emergency funding to continue in the short term.
Most likely they will get it. I also think this will be in court and negotiations for a while. My bigger fear is that the older docs will simply retire and the younger ones head to greener pastures before this all settles out. But don't be discouraged---I don't think there has ever been a situation where a community of 150,000 suddenly loses most of its healthcare at the hands of an overzealous bureaucracy. The term "bailout" comes to mind.

[Rainger99]

This is a document from the bankruptcy filing. It appears to be getting nasty.

Check out paragraph 1 which states that the debtor (TVH) erroneously sought and received about $350 million “chiefly from UHC.”

Who paid out the money for the errors? UHC, Medicare, or someone else?

https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008182580000000001.pdf

[margaretmattson]

///

[tophcfa]

This is a document from the bankruptcy filing. It appears to be getting nasty.

Check out paragraph 1 which states that the debtor (TVH) erroneously sought and received about $350 million “chiefly from UHC.”

Who paid out the money for the errors? UHC, Medicare, or someone else?

https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008182580000000001.pdf

Yikes, just read the above posted bankruptcy court filing. Looks like two very powerful parties got into bed together and things ultimately turned out very nasty between them. It appears that in this case, the dirty laundry is not going to get swept under the bed since neither of the parties will back down because of the fear of a long and expensive legal battle. This could get very messy and not be a good thing. And if the message being portrayed in this filing is accurate, it goes a long way toward answering the ongoing question of where did the money go. Sincerely hoping this doesn’t turn into a real life tale of success turning into power and greed that ultimately leads to corruption?

[BrianL99]

This is a bankruptcy filing..... It seems court documents filed are questioning the bankruptcy. Does this business truly have more debt than assets? Should the Morse family be required to liquidate assets associated with this business to pay some of the debt? This is what the court will decide.


Please, identify just one sentence in the entire filing, that suggests that TVH is not bankrupt?

[BrianL99]

This is a document from the bankruptcy filing. It appears to be getting nasty.

Check out paragraph 1 which states that the debtor (TVH) erroneously sought and received about $350 million “chiefly from UHC.”

Who paid out the money for the errors? UHC, Medicare, or someone else?

https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008182580000000001.pdf

The Motion in Opposition, accuses TVH of disbursing cash to the Morse family, to hide it from the Bankruptcy Court and creditors. This seems to be a new accusation.

The Motion also identifies a purported strategy to limit the Morse Family & TVH's liability for the Medicare overpayments.

I thought Paragraph 27 & 28 sort of summed everything up.

[Rainger99]

Interesting filing.

The monthly operating report for TVH for July.


https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008212580000000078.pdf

[Rainger99]

Now Florida Blue (FB) is objecting to portions of the bankruptcy.

One of the more interesting comments from Florida Blue is the following:

This “problem” turned out to be a four years’ long scheme to add diagnostic codes to patient files that resulted in overpayments by Florida Blue to the Debtor of approximately $25 million.

I am not a lawyer but it seems that TVH wants to pay FB $0 and FB thinks they are entitled to $25 million.

The entire document is only 8 pages long.

https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008212580000000132.pdf

[golfing eagles]

Now Florida Blue (FB) is objecting to portions of the bankruptcy.

One of the more interesting comments from Florida Blue is the following:

This “problem” turned out to be a four years’ long scheme to add diagnostic codes to patient files that resulted in overpayments by Florida Blue to the Debtor of approximately $25 million.

I am not a lawyer but it seems that TVH wants to pay FB $0 and FB thins they are entitled to $25 million.

The entire document is only 8 pages long.

https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008212580000000132.pdf

I think that should read "The ACCUSATION...."

[Rainger99]

I think that should read "The ACCUSATION...."

I believe they took the word problem directly from the letter from TVH’s CEO.


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

[tophcfa]

Now Florida Blue (FB) is objecting to portions of the bankruptcy.

One of the more interesting comments from Florida Blue is the following:

This “problem” turned out to be a four years’ long scheme to add diagnostic codes to patient files that resulted in overpayments by Florida Blue to the Debtor of approximately $25 million.

I am not a lawyer but it seems that TVH wants to pay FB $0 and FB thins they are entitled to $25 million.

The entire document is only 8 pages long.

https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008212580000000132.pdf

Yikes, more bad news for TVH. Add Blue Cross and Blue Shield to the mix of Medicare Advantage Insurers objecting to the terms of the bankruptcy filing. They strongly imply that TVH engaged in a multiple year scheme to add diagnostic codes to patient files that resulted in overpayment by Florida Blue to TVH of approximately 25 million (not including 2025). Blue Cross is further claiming that TVH must repay these overpayments to Florida Blue, or they will object to the assignment of their Medicare Advantage contracts to any entity that acquires TVH. The bankruptcy filing by TVH claimed they don’t owe Florida Blue anything, which Blue Cross vehemently disagrees with. This obviously throws an additional monkey wrench into the whole process. Florida Blue wants to be reimbursed for overpayments resulting from miscoding by TVH. Without reimbursements, they want to void the assignment of their customers MA contracts, making TVH less attractive to any buyer. Furthermore, this very well might give CenterWell/Humana an opening to back out of the Stalking Horse agreement to purchase TVH because of a material change in value. And finally, this gives further evidence to the bankruptcy court that the bankruptcy filing by TVH includes questionable information that necessities more detailed legal discovery. It has become very clear that TVH wants this process expedited ASAP, with little to no discovery. Every time another bankruptcy court filing comes out this case gets more complicated, potentially extending the outcome and requiring a much deeper dive into TVH’s accounting activities and diagnostic coding practices. Not a good thing for TVH, it’s patients, and residents of the Villages in general.

[dewilson58]

"a multiple year scheme"...................click bait.

"the Debtor’s CEO disclosed to........................" first time I heard about the self admission.

[golfing eagles]

Now Florida Blue (FB) is objecting to portions of the bankruptcy.

One of the more interesting comments from Florida Blue is the following:

This “problem” turned out to be a four years’ long scheme to add diagnostic codes to patient files that resulted in overpayments by Florida Blue to the Debtor of approximately $25 million.

I am not a lawyer but it seems that TVH wants to pay FB $0 and FB thinks they are entitled to $25 million.

The entire document is only 8 pages long.

https://cases.stretto.com/public/x458/13910/PLEADINGS/1391008212580000000132.pdf

I think that should read "The ACCUSATION...."

I believe they took the word problem directly from the letter from TVH’s CEO.


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

OK, now for the facts:

The post I responded to:

This “problem” turned out to be a four years’ long scheme to add diagnostic codes to patient files that resulted in overpayments by Florida Blue to the Debtor of approximately $25 million.

And now the quote from the actual letter:

Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices.

Does anyone think those two statements have the same meaning????

[drducat]

Florida Blue wants their $25 million back before they allow a contract transfer over to the new stalking horse owner or bidder that wins. This could cause an issue for the end of year care for those of us whom have that coverage.

[golfing eagles]

Florida Blue wants their $25 million back before they allow a contract transfer over to the new stalking horse owner or bidder that wins. This could cause an issue for the end of year care for those of us whom have that coverage.

Perhaps, but not very likely.

TVH can't stop accepting UHC and Florida Blue, they'd have no patients left.

UHC and Florida Blue could drop TVH from their panel of providers, but the optics of dropping 50,000 covered lives in a small geographic area wouldn't look good, and probably garner the attention of our politicians and regulatory authorities.

Hopefully the dozens of lawyers involved won't get into a "p!$$!ng" contest at the expense of Villager's health care.

Besides, it's not yet clear that TVH owes FB anything and $25M is chump change to Blue Cross

[tophcfa]

"a multiple year scheme"...................click bait.

“a four years’ long scheme” is the exact wording used by the Blue Cross attorneys in the bankruptcy court filing. See page 3, subsection 6, and read it for yourself.

It’s doubtful that the attorneys are trying to impress the bankruptcy court judge with click bait. I’m sure that wording was carefully thought out before being included in the court filing.

[golfing eagles]

“a four years’ long scheme” is the exact wording used by the Blue Cross attorneys in the bankruptcy court filing. See page 3, subsection 6, and read it for yourself.

It’s doubtful that the attorneys are trying to impress the bankruptcy court judge with click bait. I’m sure that wording was carefully thought out before being included in the court filing.

Really. I thought he whole point of endless motions and legal theatrics IS to impress a judge or jury, and in this case sway public opinion and that of government investigators as well.

[Rainger99]

Really. I thought he whole point of endless motions and legal theatrics IS to impress a judge or jury, and in this case sway public opinion and that of government investigators as well.

There seems to be a dispute as to the definition of clickbait.

Clickbait uses sensational, misleading, or curiosity-provoking headlines and images to drive traffic to content that may not deliver on its promise.

[golfing eagles]

There seems to be a dispute as to the definition of clickbait.

Clickbait uses sensational, misleading, or curiosity-provoking headlines and images to drive traffic to content that may not deliver on its promise.

In other words, 99.9% of all social media :1rotfl::1rotfl::1rotfl:

[tophcfa]

Really. I thought he whole point of endless motions and legal theatrics IS to impress a judge or jury, and in this case sway public opinion and that of government investigators as well.

It wouldn’t impress a judge or jury to make false claims in a court filing when the real facts come out during discovery. Peeling back the onion, it appears that both United Health Care and Blue Cross are pushing for the court to engage in a thorough discovery process, while TVH is pushing for an expedited sale while attempting to bury the discovery process. One is free to read into that as they choose.

[Bill14564]

It wouldn’t impress a judge or jury to make false claims in a court filing when the real facts come out during discovery. Peeling back the onion, it appears that both United Health Care and Blue Cross are pushing for the court to engage in a thorough discovery process, while TVH is pushing for an expedited sale while attempting to bury the discovery process. One is free to read into that as they choose.

But haven't you already read into it for us by "peeling back the onion?"

TVH seems to be pressing forward with the sale. UHC and BC are attempting to slow the sale. Any statements as to their motives are conjecture.

[tophcfa]

TVH seems to be pressing forward with the sale. UHC and BC are attempting to slow the sale. Any statements as to their motives are conjecture.

Agree, but wouldn’t you also agree, that generally speaking, parties that would benefit from all the facts being discovered would want to put on the brakes so there is time for a thorough discovery process can take place?

[Bill14564]

Agree, but wouldn’t you also agree, that generally speaking, parties that would benefit from all the facts being discovered would want to put on the brakes so there is time for a thorough discovery process can take place?

Sure, but is this about benefiting from all the facts being discovered or is this about slowing the sale in order to increase pressure on the other party to capitulate in some way? I don't know. Certainly, all parties are working towards their individual self interests but that is not evidence of some nefarious scheme or ulterior motive.

[dewilson58]

There seems to be a dispute as to the definition of clickbait.

Clickbait uses sensational, misleading, or curiosity-provoking headlines and images to drive traffic to content that may not deliver on its promise.

No dispute on my end.

The statement is sensationalism.
This is what lawyers do............in court and out of court.
A "scheme" has not been proven.

[tophcfa]

Sure, but is this about benefiting from all the facts being discovered or is this about slowing the sale in order to increase pressure on the other party to capitulate in some way? I don't know. Certainly, all parties are working towards their individual self interests but that is not evidence of some nefarious scheme or ulterior motive.

I see your point, but why would the other party capitulate under pressure if they felt they did nothing wrong? Thinking logically, they should welcome a lengthy process, including a thorough and full discovery, as this would exonerate them. There is no doubt all parties are working towards their individual self interests.

[Rainger99]

No dispute on my end.

The statement is sensationalism.
This is what lawyers do............in court and out of court.
A "scheme" has not been proven.

And neither has TVH proved that there was no scheme.

However, Florida Blue has made a very specific statement in their papers:

They state that "a Florida Blue investigation revealed that in payment year 2024, the Debtor had falsely added the following diagnoses into patient files:
Diagnostic Code 48 for "Coagulation Defects and Other Specified Hematological Disorders," and Diagnostic Code 22 related to “specified Heart Arrhythmias.”

That does not look like clickbait.

[Rainger99]

In other words, 99.9% of all social media :1rotfl::1rotfl::1rotfl:

Except for TOTV!

[Bill14564]

I see your point, but why would the other party capitulate under pressure if they felt they did nothing wrong? Thinking logically, they should welcome a lengthy process, including a thorough and full discovery, as this would exonerate them. There is no doubt all parties are working towards their individual self interests.

The reported reason is they have a cash flow problem and are finding it hard to make payroll. Also, their patients are worried and the longer this goes on the more likely it is that they will lose some.

Other possibilities notwithstanding, there are good business reasons for TVH to want the sale to close quickly. Being exonerated is a small consolation if the business fails in the meantime.

(and yes, there are other possibilities)

[tophcfa]

The reported reason is they have a cash flow problem and are finding it hard to make payroll.

Cash flow problem? According to the UHC bankruptcy court filing, TVH admitted on the seventh week of this case, that it distributed $183 million between 2022 and 2024. UHC further claims the DIP financing is being provided by key insiders of TVH (the same parties that benefited from the distributions), which is highly unusual and suspicious. None of that proves anything, but it certainly takes the teeth out of the cash flow problem argument.

[golfing eagles]

And neither has TVH proved that there was no scheme.

However, Florida Blue has made a very specific statement in their papers:

They state that "a Florida Blue investigation revealed that in payment year 2024, the Debtor had falsely added the following diagnoses into patient files:
Diagnostic Code 48 for "Coagulation Defects and Other Specified Hematological Disorders," and Diagnostic Code 22 related to “specified Heart Arrhythmias.”

That does not look like clickbait.

This is a very, very interesting post.

First of all, TVH doesn't have to prove there was no "scheme", the burden of proof is upon the accusers

Secondly, ICDM-10 diagnostic codes are generally 7 digits with 2 digit modifiers---but there are some less specific codes for generalized diagnoses, the one for coagulation defects is actually D68.8

That being said, remember my point all along has been that nobody knows what happened so nobody should rush to judgement, especially with torches and pitchforks.
But if I can "conjecture", as I've been accused, of, let's consider this, and I'll direct it at "Coagulation Defects and Other Specified Hematological Disorders" as an example

Anyone taking aspirin, even 1/4 of a baby aspirin per day, has platelet dysfunction by definition---that's the purpose of taking it. If a physician wants to make a big deal out of this and use that "Coagulation Defects and Other Specified Hematological Disorders" diagnosis, they should put something, anything, in the note---"I discussed aspirin use with the patient", "The patient denies excessive bruising", the patient has not had nosebleeds", etc. And that would totally justify the submission of that code, which might result in a higher payment.

They might believe that simply having aspirin in the patient's medication list would suffice because all physicians know this. However, the bean counters would have no idea and would look for something in the progress note to justify the use of that diagnosis. But overall, since TVH physicians are on salary, no single physician would have a reason to push the limits that far. To make it work there would have to be a conspiracy of 60 or 70+ providers , which is highly unlikely

But, to speculate further, what IF someone at the coding level or even higher on the food chain directed those coders to "add" the diagnosis of D68.8 to anyone with aspirin in their medication list??? Strictly speaking it's 100% legitimate, EXCEPT none of the progress notes would indicate anything relating to aspirin use. Hence the term "The documentation failed to support the diagnosis submitted", and now you have "overbilling". It's possible. Or somebody with access and who is tech savvy could simply program the EMR to add that diagnosis to anyone on aspirin.

So let's just see how the story develops. Unfortunately, at this point, the only winners that I see emerging from this are the lawyers.

[Bill14564]

Cash flow problem? According to the UHC bankruptcy court filing, TVH admitted on the seventh week of this case, that it distributed $183 million between 2022 and 2024. UHC further claims the DIP financing is being provided by key insiders of TVH (the same parties that benefited from the distributions), which is highly unusual and suspicious. None of that proves anything, but it certainly takes the teeth out of the cash flow problem argument.

To the contrary, if all that cash was distributed and then they came across the billing issue and now UHC is withholding payments it reinforces the cash flow argument.

[Rainger99]

Unfortunately, at this point, the only winners that I see emerging from this are the lawyers.

I think everyone can agree with that statement!

[golfing eagles]

To the contrary, if all that cash was distributed and then they came across the billing issue and now UHC is withholding payments it reinforces the cash flow argument.

If there were significant cash distributions along the way, and if there was significant "overbilling", that is a huge issue apart from cash flow. Forensic accounting will tell.

[dewilson58]

And neither has TVH proved that there was no scheme.



Welcome to USA..................innocent until proven guilty.

:clap2::clap2:

[dewilson58]

They state that "a Florida Blue investigation revealed that in payment year 2024, the Debtor had falsely added the following diagnoses into patient files:


That does not look like clickbait.

:shrug::shrug::shrug:

"falsely" does not mean a scheme.

Also, if someone makes a statement (like "falsely") it doesn't make it true.

Here, let me show you.................The sky is falling.
Go outside, the sky is not falling.

:jester:

[golfing eagles]

:shrug::shrug::shrug:

"falsely" does not mean a scheme.

Also, if someone makes a statement (like "falsely") it doesn't make it true.

Here, let me show you.................The sky is falling.
Go outside, the sky is not falling.

:jester:

Welcome to the shark tank.

TVH, UHC, Florida Blue, Humana, CMS and possibly DOJ---each with an army of lawyers.

What could possibly go wrong? :1rotfl::1rotfl::1rotfl:

[dewilson58]

Welcome to the shark tank.

TVH, UHC, Florida Blue, Humana, CMS and possibly DOJ---each with an army of lawyers.

What could possibly go wrong? :1rotfl::1rotfl::1rotfl:

Meta is reading ToTV.............she jus did an article with the word scheme.....clickbait.

:eclipsee_gold_cup:

[Bill14564]

If there were significant cash distributions along the way, and if there was significant "overbilling", that is a huge issue apart from cash flow. Forensic accounting will tell.

Distributions in the form of paying off debt according to the reporting. UHC and perhaps FB characterize it differently.

But my point was simply that if:
- TVH distributed cash reserves that it had with the understanding that future cash flows would be high;
- TVH discovered an error which not only reduced cash flows but raised the potential for a significant additional debt; and,
- UHC is now withholding reimbursements to TVH

then that supports a TVH claim of a cash flow issue today.

[Pat2015]

I’ll bet there are 100 lawyers listed as being involved in the case and none of them could explain it.
How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?
Because it’s going to be a fire sale. Also, it’s $360 million owed to the government, and Florida Blue is filing against them for another $25 million. Lot’s more insurance companies will be adding on as the Specialists take all kinds of insurance and the fraudulent billing scheme would not just be the government and BCBS.

[golfing eagles]

Because it’s going to be a fire sale. Also, it’s $360 million owed to the government, and Florida Blue is filing against them for another $25 million. Lot’s more insurance companies will be adding on as the Specialists take all kinds of insurance and the fraudulent billing scheme would not just be the government and BCBS.

Again, and I think this is about 50 times: WHAT FRAUDULENT BILLING "SCHEME"???? The only accusations of fraud are coming from uninformed, unsubstantiated posts on TOTV. Neither CMS or DOJ has made any accusation of fraud. Will there be a charge of fraud in the future? Who knows, but certainly NOT posters on TOTV. So those uninformed people should put down their torches and pitchforks for the time being until more is known.

[tophcfa]

Because it’s going to be a fire sale. Also, it’s $360 million owed to the government, and Florida Blue is filing against them for another $25 million. Lot’s more insurance companies will be adding on as the Specialists take all kinds of insurance and the fraudulent billing scheme would not just be the government and BCBS.

As far as I can tell, the $25 million is part of the overall $360 million. I’ve been asking myself, why would Florida Blue dive into this hornets nest to recover $25 million, which is chump change for a Company like Blue Cross and Blue Shield? My best guess is it’s not about the $25 million, it’s about preventing the possibility of a dangerous legal precedent being set. If the bankruptcy court ultimately lets TVH off the hook for the $360 million, then CMS might go after the likes of United Healthcare, Florida Blue, and Humana to recover the funds. If CMS were to successfully do that, it would set a legal precedent that any health care provider, similar to TVH, could simply file chapter 11 and force over billing liabilities onto the insurance companies they have MA contracts with. That scenario would create a very dangerous precedent for insurers, potentially exposing them to unquantifiable liabilities and change the whole landscape of the Medicare Advantage business for them.

[drducat]

As far as I can tell, the $25 million is part of the overall $360 million. I’ve been asking myself, why would Florida Blue dive into this hornets nest to recover $25 million, which is chump change for a Company like Blue Cross and Blue Shield? My best guess is it’s not about the $25 million, it’s about preventing the possibility of a dangerous legal precedent being set. If the bankruptcy court ultimately lets TVH off the hook for the $360 million, then CMS might go after the likes of United Healthcare, Florida Blue, and Humana to recover the funds. If CMS were to successfully do that, it would set a legal precedent that any health care provider, similar to TVH, could simply file chapter 11 and force over billing liabilities onto the insurance companies they have MA contracts with. That scenario would create a very dangerous precedent for insurers, potentially exposing them to unquantifiable liabilities and change the whole landscape of the Medicare Advantage business for them.
The court can't discharge the 361 million owed the federal government CMS. Nor can it discharge a penalty that is mandatory for things like this. It won't matter if it is fraud or otherwise a penalty can't be included.

[Rainger99]

Welcome to USA..................innocent until proven guilty.

:clap2::clap2:

You are correct that in a criminal action, the burden is always on the government. However, this is not a criminal action. It is a bankruptcy action. And it has different burdens of proof.

When a creditor files a bankruptcy claim using the correct official form and with supporting documents, it is treated as "prima facie evidence" of its validity and amount.

Prima facie evidence means the claim is presumed to be correct on its face.

The creditor's burden at this stage is simply to file the claim properly and on time.

If the debtor (or another interested party) objects to the claim, the burden of proof shifts to that objecting party.

I haven’t seen any evidence that TVH has objected to any claims, much less produce any evidence that the claims are defective.

[tophcfa]

You are correct that in a criminal action, the burden is always on the government. However, this is not a criminal action. It is a bankruptcy action. And it has different burdens of proof.

When a creditor files a bankruptcy claim using the correct official form and with supporting documents, it is treated as "prima facie evidence" of its validity and amount.

Prima facie evidence means the claim is presumed to be correct on its face.

The creditor's burden at this stage is simply to file the claim properly and on time.

If the debtor (or another interested party) objects to the claim, the burden of proof shifts to that objecting party.

I haven’t seen any evidence that TVH has objected to any claims, much less produce any evidence that the claims are defective.

Very interesting, was not aware of that. So if the debtor (TVH) objects to the creditors claims, the burden of proof shifts to them to prove the claims are false. If they don’t object, then the claims are considered correct. By this logic, the creditors are forcing disclosure/discovery onto the party filing for bankruptcy (TVH). Kind of puts TVH between a rock and a hard place if they are indeed trying to avoid opening up their books to full discovery. It will be interesting to see if TVH objects to any of the creditor claims, exposing them to discovery?

[Bill14564]

Very interesting, was not aware of that. So if the debtor (TVH) objects to the creditors claims, the burden of proof shifts to them to prove the claims are false. If they don’t object, then the claims are considered correct. By this logic, the creditors are forcing disclosure/discovery onto the party filing for bankruptcy (TVH). Kind of puts TVH between a rock and a hard place if they are indeed trying to avoid opening up their books to full discovery. It will be interesting to see if TVH objects to any of the creditor claims, exposing them to discovery?

Or, TVH replies, "yes, that is correct, that is one of our debts and that is why we are restructuring under Chapter xx."

Did the creditors file a claim against the TVH assets under bankruptcy rules or did they file something different and outside those rules? I really don't know (or particularly care) but the details will matter quite a bit in court.

[Rainger99]

Very interesting, was not aware of that. So if the debtor (TVH) objects to the creditors claims, the burden of proof shifts to them to prove the claims are false. If they don’t object, then the claims are considered correct. By this logic, the creditors are forcing disclosure/discovery onto the party filing for bankruptcy (TVH). Kind of puts TVH between a rock and a hard place if they are indeed trying to avoid opening up their books to full discovery. It will be interesting to see if TVH objects to any of the creditor claims, exposing them to discovery?

Here is an article from a law firm discussing burden of proof in bankruptcy actions.

Asserting a Proof of Claim in Bankruptcy (https://www.scura.com/blog/asserting-proof-of-claim-in-bankruptcy)

Hopefully we have some bankruptcy lawyers on TOTV that can elaborate on the issue.

I still don’t understand why Medicare is the main creditor instead of UHC, Humana, or Florida Blue.

[tophcfa]

Here is an article from a law firm discussing burden of proof in bankruptcy actions.

Asserting a Proof of Claim in Bankruptcy (https://www.scura.com/blog/asserting-proof-of-claim-in-bankruptcy)

Hopefully we have some bankruptcy lawyers on TOTV that can elaborate on the issue.

I still don’t understand why Medicare is the main creditor instead of UHC, Humana, or Florida Blue.

Thanks for the link. To try to answer your question as best I can, reading through the bankruptcy court filing by Florida Blue, on page 3 section 5, it states that typically 90% of overpayments are passed along from Florida Blue to the debtor (TVH).

[BrianL99]

I still don’t understand why Medicare is the main creditor instead of UHC, Humana, or Florida Blue.

I've asked the question a couple of times.

The only scenario that seems to make sense, is TVH is some sort of "Licensee" of the various insurance companies and they bill Medicare directly, as the Provider.

As you point out, if UHC, Humana or FB was the "Provider", they would be the one that owe the money.

[tophcfa]

I've asked the question a couple of times.

The only scenario that seems to make sense, is TVH is some sort of "Licensee" of the various insurance companies and they bill Medicare directly, as the Provider.

As you point out, if UHC, Humana or FB was the "Provider", they would be the one that owe the money.

It’s confusing, see the above post (#137). TVH is the provider or medical services and determines the diagnostic codes that are submitted to CMS. Based on the diagnostic codes, CMS makes the payments to the patients Medicare Advantage insurer. According to Florida Blue, typically 90% of those payments are passed through to the provider, which is TVH in this case. So in this case, the biggest creditor, which is Medicare (via CMS), is due back 90% of any overpayments collected by the debtor/provider (TVH). I guess theoretically, the MA insures (United Health Care, Florida Blue, Humana) are on the hook to pay back the other 10% of the overpayments to CMS that were not passed through to TVH, but as far as I can tell that isn’t part of the bankruptcy case in question.

[Rainger99]

It’s confusing, see the above post (#137). TVH is the provider or medical services and determines the diagnostic codes that are submitted to CMS. Based on the diagnostic codes, CMS makes the payments to the patients Medicare Advantage insurer. According to Florida Blue, typically 90% of those payments are passed through to the provider, which is TVH in this case. So in this case, the biggest creditor, which is Medicare (via CMS), is due back 90% of any overpayments collected by the debtor/provider (TVH). I guess theoretically, the MA insures (United Health Care, Florida Blue, Humana) are on the hook to pay back the other 10% of the overpayments to CMS that were not passed through to TVH, but as far as I can tell that isn’t part of the bankruptcy case in question.

This is my question.

Every Medicare patient has an individual health score called RAF. An RAF of 1 is average and anything above 1 means that your health is below average and anything that is below 1 means your health is better than average. Medicare has a fixed rate per county to determine the value of 1. Assume that it is $1,000 for Sumter County.

In that case, Medicare would pay advantage plans $1,000 for every patient rated 1 and $1,500 for every patient rated 1.5. I think Medicare determines the RAF score based on the doctor’s evaluation of your health. I don’t think advantage plans have anything to do with RAF scores but I could be wrong on that point.

Since the money goes directly to the advantage plans, I don’t understand how TVH benefits from having patients being rated with high RAF scores. If a person that should be a 1 is rated 1.5, I would think that the patient would not need $1,500 a month in treatment but would need only $1,000. Does that extra $500 go to TVH or remain with the advantage insurer?

Florida Blue mentioned something about 90% of the overpayments going to TVH. How does that happen?

I obviously don’t understand how it works but someone should have a basic understanding of Medicare reimburse procedures.