[golfing eagles]

Originally Posted by Topspinmo

Does frogs fart in water?

If that is an analogy that assumes (like many others) that this is intentional misrepresentation (fraud), why not wait until any investigations are complete and the whole situation is adjudicated before jumping to any conclusions???

[Aces4]

Originally Posted by golfing eagles

By altering them or amending them----the usual way

According to my sources, (having been through a recent miscoding and claim denial), only the provider or their coders have the ability to submit, change or correct a claim. I was advised the supplemental insurance company (UHC) has no hand in the codes provided and cannot change them. The changes must come through the provider and this issue occurred a little over a year ago.

[golfing eagles]

Originally Posted by Aces4

According to my sources, (having been through a recent miscoding and claim denial), only the provider or their coders have the ability to submit, change or correct a claim. I was advised the supplemental insurance company (UHC) has no hand in the codes provided and cannot change them. The changes must come through the provider and this issue occurred a little over a year ago.

In theory

[CoachKandSportsguy]

Originally Posted by Aces4

According to my sources, (having been through a recent miscoding and claim denial), only the provider or their coders have the ability to submit, change or correct a claim. I was advised the supplemental insurance company (UHC) has no hand in the codes provided and cannot change them. The changes must come through the provider and this issue occurred a little over a year ago.

So, UHC falling back on process, correct, however, UHC has to provide the coding for the provider to be paid in the first place. If UHC is asked by the provider the reimbursement rates by coding, they will still fall back upon on the process for plausible deniability, even though they provided information, maybe with encouragement (need voice recordings for that, though there are defenses for that to insure that they don't get caught).

So per the UHC contract for reimbursement rates, who does provide the codes for the provider to use? certainly UHC or is there a universal standard for procedure codes for everyone to use for each procedure?

[Rainger99]

Originally Posted by CoachKandSportsguy

So, UHC falling back on process, correct, however, UHC has to provide the coding for the provider to be paid in the first place. If UHC is asked by the provider the reimbursement rates by coding, they will still fall back upon on the process for plausible deniability, even though they provided information, maybe with encouragement (need voice recordings for that, though there are defenses for that to insure that they don't get caught).

So per the UHC contract for reimbursement rates, who does provide the codes for the provider to use? certainly UHC or is there a universal standard for procedure codes for everyone to use for each procedure?

I think the AMA created CPT codes.


CPT(R) overview and code approval | American Medical Association

[CoachKandSportsguy]

Originally Posted by Rainger99

I think the AMA created CPT codes.

so then a dentist office would only have about 10 codes or so that they would ever use, so that coding mistakes should be minimal, unless the particular payee contractual rate is very low, such that a coding error which is more profitable is used to probe which patients are more knowledgable or payment sensitive than others. . then a dentist caught by a customer can always blame the cheap labor for coding. . everyone has plausible deniability for errors, no?

seems stacked against the average busy person who just pays bills. .

time for dental codes to be shared here on TOTV by dental service provider per plan. . .
there is power in numbers

[golfing eagles]

Originally Posted by Rainger99

I think the AMA created CPT codes.


CPT(R) overview and code approval | American Medical Association

The AMA created CPT codes.
The RBRVS scale was created by a Harvard economist
and ICDM-10 codes were :

The ICD-10 Clinical Modification (ICD-10-CM) was developed by the U.S. Department of Health and Human Services as an adaptation of the ICD-10 with authorization from the World Health Organization (WHO). The U.S. National Center for Health Statistics (NCHS) received permission from the WHO to create a clinical modification of the ICD-10, which was first adopted in the United States in 2015.

HHS and WHO---now there's 2 organizations that have a combined IQ less than the average shoe size

[Rainger99]

Originally Posted by CoachKandSportsguy

so then a dentist office would only have about 10 codes or so that they would ever use, so that coding mistakes should be minimal.

Dentists use CDT and CPT codes. And it appears they have a lot more than 10!!

Here's a breakdown:
CDT Codes (Dental Procedures):
Diagnostic: D0100-D0999 (e.g., D0120 - Periodic oral evaluation, D0150 - Comprehensive oral evaluation).
Preventive: D1000-D1999 (e.g., D1110 - Prophylaxis, adult, D1351 - Sealant).
Restorative: D2000-D2999 (e.g., D2330 - Resin-based composite - one surface, anterior, D2740 - Crown - porcelain/ceramic substrate).
Endodontics: D3000-D3999 (e.g., D3310 - Endodontic therapy, anterior tooth).
Periodontics: D4000-D4999 (e.g., D4341 - Periodontal scaling and root planing, D4910 - Periodontal maintenance).
Prosthodontics, removable: D5000-D5899 (e.g., complete and partial dentures).
Maxillofacial prosthetics: D5900-D5999.
Prosthodontics, fixed: D6000-D6999 (e.g., implants, bridges).
Oral and Maxillofacial Surgery: D7000-D7999 (e.g., extractions, biopsies).
Orthodontics: D8000-D8999.
Adjunctive general services: D9000-D9999 (e.g., anesthesia, consultations, case presentations).


CPT Codes (Medical Procedures):
Evaluation and Management: 99201-99499 (e.g., for medical evaluations related to dental procedures).
Anesthesia: 00100-01999; 99199-99150 (e.g., for anesthesia services during dental procedures).
Surgery: 10000-69990 (e.g., for surgical procedures like jaw reconstruction).
Radiology: 70000-79999 (e.g., for CT scans of the maxillofacial area, 3D rendering).
Pathology and Laboratory: 80000-89398 (e.g., for lab tests related to dental conditions).
Medicine: 90281-99099; 99151-99199; 99500-99607 (e.g., for medical management of dental issues).

One of the problems with CPT coding is that they are copyrighted by the AMA.

CPT(R) licensing frequently asked questions (FAQs) | American Medical Association

[tophcfa]

Originally Posted by Rainger99

UnitedHealth says it's under federal investigation for civil fraud - CBS News

United Healthcare writes both Medicare Advantage and Supplemental plans. However, the fraud investigation is only focused on their Medicare Advantage line of business. Whenever something appears too good to be true, it’s typically because it is. In this case, the too good to be true was for MA policyholders, not taxpayers. Be prepared for MA premiums to increase and the free stuff not offered with Supplemental plans to disappear.

[spinner1001]

Originally Posted by Aces4

According to my sources, (having been through a recent miscoding and claim denial), only the provider or their coders have the ability to submit, change or correct a claim. I was advised the supplemental insurance company (UHC) has no hand in the codes provided and cannot change them. The changes must come through the provider and this issue occurred a little over a year ago.

The process for Medicare Advantage is different — and complicated.

[Priebehouse]

Originally Posted by dewilson58

Never thought about that...........Hmmmmm.

Swamp gas?????

[Cliff Fr]

[QUOTE=golfing eagles;2448427]Unless the plan was to eventually sell right from the beginning in 2012. Negotiations for a sale began BEFORE the discovery of the mistake in billing[/QUOTE

Big question is did Villages Healthcare already know about
the billing error? I don't think they did.

[Eg_cruz]

Originally Posted by golfing eagles

Not yet, time will tell. What if most of the $361M was coded by UHC and not TVH??? There would be a lot of posters on TOTV eating crow morning, noon, and night.

Didn’t TVH admit they own Medicare $351M
In his letter he didn’t point his finger to UHC
What about the other 200 creditors TVH owes close to $200M too

[daniel200]

Originally Posted by golfing eagles

Unless the plan was to eventually sell right from the beginning in 2012. Negotiations for a sale began BEFORE the discovery of the mistake in billing

Lol, you mean before the public discovered the billing irregularities.

[Aces4]

Originally Posted by spinner1001

The process for Medicare Advantage is different — and complicated.

It always is when private insurance gets involved.