[Cliff Fr]

You might want to research what happened with Rick Scott's medicare fraud situation.

[golfing eagles]

Originally Posted by elle123

So will these criminals repay the $350 million stolen in their Medicare fraud scheme? Will they be appropriately prosecuted considering the magnitude of this fraud? Let's see how it all plays out.

Interesting, EXCEPT:

They are NOT criminals
They did NOT "steal" anything
There is NO accusation of fraud except on TOTV
There is NO prosecution planned

Amazing where some people get their bizarre ideas from

[Ellwoodrick]

My complements to Idlewild. Something not often found on TOV a well thought out, well researched and well written Post.

Just had to say.....

[golfing eagles]

Originally Posted by Ellwoodrick

My complements to Idlewild. Something not often found on TOV a well thought out, well researched and well written Post.

Just had to say.....

Except, AI is just a very sophisticated computer program, so as the old saying goes---"Garbage in, garbage out"

[Ken D.]

Originally Posted by Rainger99

I did not see any political references in the OP.

So, who owns Talk of The Villages platform?

[revfiddle]

Thanks for posting. Interesting, and will have implications for all in the TV.

[Rocksnap]

OP
Wow! Thanks for your thorough and informative detective work. I’m not looking for anyone to get into trouble. It will be interesting just how this whole thing unfolds. And even more interesting how the Bank side of things was sold off just before this whole thing was announced. That alone appears to look like guilt. As you would think that aspect would be a tightly held money/deal maker for the TV machine.
There are a lot of moving parts here. It will be interesting just how this all unfolds. I’m thinking the Morse family has a little pucker factor going on right now.

[ZPaul]

Bad timing for this problem to come up given the weaker real estate market. Sale of banking assets improved liquidity of developer family. Having worked in Healthcare finance, regulations are more complex than the IRS rules and as subject to interpretation. Much bigger operators have run into similar problems. Attempt to sell healthcare operations always triggers buyer's due diligence reviews. Due diligence process tries to dig up any potential problems so buyer will not need to deal with them. Normal on healthcare acquisition to question all medicare/medicaid reimbursement filings and look for anything that could be interpreted as subject to challenge. The Morse family got in way over their heads getting into healthcare. The fact that they tried to sell the operation pretty much proves that they were not aware of the issues. It would most likely never have been detected without the due diligence process. Biggest concern right now is a very large bill suddenly due at a time when cashflow from new development is weak.

Existing village operations should be safe as they are organized into resident owned homes and common areas owned by Districts. These entities are legally independent and are not involved in the Healthcare dispute. Potential impact on new development areas where developer cash problems could slow down lot sales/construction and buildout of promised common areas, although new common areas partly shielded by Development District structure. Unlikely to be able to do any new Development District Bonds until everything sorted out since bondholders hate uncertainty.

[Rainger99]

Originally Posted by golfing eagles

Not even close to how it works for MA plans and TVH

If that is not how it works, can you explain how it works?

It appears to be very complicated and it even appears that TVH didn’t understand how it works or they wouldn’t be in Chapter 11.

[Annie66]

Originally Posted by golfing eagles

Except, AI is just a very sophisticated computer program, so as the old saying goes---"Garbage in, garbage out"

It's so easy to throw shade. How about explaining specifically what you saw in his post that was objectionable or false?

[Annie66]

Just speculating here ..... Is it conceivable that the Morse family will have to sell off other segments of The Village's infrastructure to pay off a possible civil judgement against them? What negative impact(s) do you think would affect our quality of life?

[Justputt]

Originally Posted by golfing eagles

Not even close to how it works for MA plans and TVH

Actually, it's pretty close. There's a professional (doctor) and technical (facility) component to billing in many cases (some have prof or tech only). The doctor makes the diagnosis and determines the course of care, consult notes, treatment plan, etc. that are used to obtain the prior authorization, when needed. For there to be this much money involved this would almost have to be a systemic problem. On the other hand, if this is a coding dispute, this could be a greedy auditor trying to get a percentage of the recovered billing. Before I retired, "Medicare" claimed we improperly used a treatment technique known as IMRT on nearly all our cases, so we had a RAC audit, and they wanted to claw back virtually all the money. We appealed all the cases and only lost one that was a close call on medical necessity. The key is having 100% of the supporting documentation before ever submitting a charge. We had weekly charge reviews where staff looked at every charge to make sure it fit and there was supporting documentation.

[golfing eagles]

Originally Posted by Rainger99

If that is not how it works, can you explain how it works?

It appears to be very complicated and it even appears that TVH didn’t understand how it works or they wouldn’t be in Chapter 11.

I'd love to but it would take hours of typing. The short version is that the doctors don't code CPT, just ICDM-10. They are employees who would benefit very little from making patients appear sicker than they really are. In addition, to suggest that 60 or 70 doctors could agree upon a criminal plan to defraud Medicare is insane---you put 10 doctors in a room and ask what 1 + 1 equals, you get 10 different answers. The ICDM-10 codes (7 digits with 2-digit modifiers) are absolutely ridiculous, very vague, and basically designed by government and insurance industry bean counters who have no idea about medicine but are collecting "data" for God knows what purpose. The majority of TVH patients have Medicare Advantage plans form either UHC or Florida Blue, which pays them a monthly stipend for each patient, and is adjusted for risk and severity of illnesses. CMS then pays the MA intermediary. But also realize that TVH is an ACO, which means when you go to, let's say the dermatologist, their fee comes out of TVH's pocket. So maybe people can understand if TVH might be unhappy with any dermatology practice that charges them triple the going rate. (hint, hint)

I have no idea what actually took place, but I highly doubt some type of widespread criminal conspiracy.

Now, what are the realistic possibilities?

Providers may have told to code as aggressively as possible without violating what they believe to be the correct guidelines. However, TVH has outside consultants look at their charges on a regular basis so this very issue does not occur, but apparently that didn't work out too well. Once negotiations for an acquisition by Humana took place, there may have been a difference of opinion as to coding methodology, which triggered self-reporting to CMS, MONTHS BEFORE DOGE EVEN EXISTED. Based on 35 years experience, this is my favored option

Somebody much higher on the TVH food chain was able to enter diagnoses and billing codes that were not supported by the documentation. But such a person would have to have a WHOLE LOT to gain considering the downside risk since that would be a fraudulent criminal act.

There is a remote possibility that there was a systemic computer glitch that resulted in overbilling---but I find this the least likely.

So, bottom line, I don't know, no one posting on TOTV knows, and we will just have to wait to see the eventual outcome. But my main reason for posting so audaciously is that I find it disingenuous to accuse any party of criminal fraud based on uniformed speculation and lead the "torches and pitchforks" brigade. like some on this site continue to do, although I acknowledge that most of them are just parroting what they have heard and read from others

[Bill14564]

Originally Posted by Annie66

It's so easy to throw shade. How about explaining specifically what you saw in his post that was objectionable or false?

That was a very, very long post. To explain specifically what, if anything, was incorrect would require knowing details of the situation that have either not been made public or are difficult to understand.

What I am concerned about is using AI as an authoritative source. AI doesn't think, AI regurgitates and amplifies. AI doesn't analyze multiple sources to determine what the truth is, AI generates words that are consistent with the sources it has ingested. If the data it has ingested is accurate then the words it generates have a good chance of being accurate. If the data it has ingested is inaccurate, incomplete, or just speculation then the words it generates will be inaccurate, incomplete, or just plain wrong (garbage in, garbage out).

AI also amplifies. It puts words together into meaningful sentences that answer a question. If details are missing or if it needs an example it will create sentences to add those. The additional sentences will be on topic and will look correct but they are amplification of the sources, not the results of critical thinking. As has been seen in reporting on some AI-generated court filings and research papers, the AI output can be pure hallucination.

As a starting point for follow-on, in-depth research, an AI-generated post is great.

As an assertion to be taken as fact, an AI-generated post is concerning.

[golfing eagles]

Originally Posted by Justputt

Actually, it's pretty close. There's a professional (doctor) and technical (facility) component to billing in many cases (some have prof or tech only). The doctor makes the diagnosis and determines the course of care, consult notes, treatment plan, etc. that are used to obtain the prior authorization, when needed. For there to be this much money involved this would almost have to be a systemic problem. On the other hand, if this is a coding dispute, this could be a greedy auditor trying to get a percentage of the recovered billing. Before I retired, "Medicare" claimed we improperly used a treatment technique known as IMRT on nearly all our cases, so we had a RAC audit, and they wanted to claw back virtually all the money. We appealed all the cases and only lost one that was a close call on medical necessity. The key is having 100% of the supporting documentation before ever submitting a charge. We had weekly charge reviews where staff looked at every charge to make sure it fit and there was supporting documentation.

Sorry, but wrong. What was described isn't far off for procedures like an MRI, where there is in fact a technical and professional component. But that in no way applies to the E&M codes used in primary care and other specialties. Furthermore , those E&M codes apply to billing for traditional Medicare, but not for Medicare Advantage Plans which are capitated. Please don't contribute to the plethora of misinformation already floating around this site.