[biker1]

The Villages (aka "the developer") essentially owns the commercial properties, the Championship Golf Courses, and the amenities (rec centers, executive golf, pools, pickleball courts, etc.) that have not yet been sold to the CDDs. These amenities are in the newer sections as it takes a couple of years before the CDDs take ownership. Pretty much everything else is under the control of the CDDs or County.

Originally Posted by 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?

[golfing eagles]

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?

Simple, 2 letters----AI

Again, AI is not an authoritarian source, it is a computer program, and I stand by my post----garbage in, garbage out. Not in all cases, but how can we know the difference?

[drducat]

What is concerning is the lack of movement with the negotiations with DOJ and CMS. The penalties involved are could exceed $500 million to a billion alone...time will tell. The we have United stirring the pot also. The rush needed is to maintain the assets ( patients) will leave during next Medicare Advantage sign up period.

[MandoMan]

Thanks for your post!
A great many hospitals, nursing homes (Yes, including you, Rick Scott), and doctors’ offices have been upcoding for decades. I think it was around 1983 that the government began reviewing the days patients stayed in the hospital and denying bills when patients were in the hospital longer than they needed to be. (My father-in-law was Chief of Medicine at a large hospital at the time, and I well remember the conversations about it around the dinner table.)

“ The federal government's involvement in influencing hospital length of stay to control costs began in earnest with the implementation of the Inpatient Prospective Payment System (IPPS) for Medicare in 1983.
Prior to this, hospitals were reimbursed on a retrospective cost basis, which meant they were paid for whatever they spent. This system offered little incentive to control costs, leading to rapidly increasing healthcare expenditures.
The IPPS, utilizing Diagnosis-Related Groups (DRGs), shifted the payment model to a prospective system. Under this system, hospitals receive a fixed payment for a patient's entire hospital stay, based on the DRG assigned to the patient's illness or procedure. If the hospital discharges the patient before exhausting the Medicare payment, they keep the difference. Conversely, if the hospital's expenses exceed the fixed payment, they must absorb the additional costs. This system incentivized hospitals to manage length of stay more efficiently to avoid exceeding the DRG-based payment and ensure their financial viability.” This is why your hospital wants to send you home as soon as possible.

Hospitals and doctors suddenly found their profits evaporating. They had two options, and many or most used both. One was upcoding diagnoses and the treatment provided. The other was itemizing bills. Hospital managers and doctors attended thousands of seminars about the latest ways to do this and what codes to use that were less likely to be denied. If you actually looked at an itemized statement of a hospital bill, you might discover that you were being billed $10 for a 25¢ box of tissues or $20 for an aspirin taken from a bottle. A bottle of IV fluid, essentially water with sugar or salt or something in it, might be billed at up to $1,000 when the hospital actually pays $20 for it. As insurance companies caught on and questioned bills, new upcoding codes were found and used. I think that is essentially what was done here at The Villages. Upcoded codes were used and paid for by the government, and of course this upcoding is always fraudulent, even if it isn’t questioned. If a company realizes it is likely to be found out, it may confess.

On the other hand, consider this. The Villages Health System might charge $5,000 for an MRI, which is about what other facilities are charging. However, that doesn’t mean the government is actually paying it. I’ve had several MRIs and CT scans here and other places in the past five years, and Medicare and my Blue Cross/Blue Shield plans combined may pay $150 of that $5000 bill and refuse to let me be billed for the rest. I had a major surgery this year with a total bill of $130,000. The hospital and doctors received only $15,000! Now, the hospital submitted a detailed and outrageous list of charges. But Medicare said “We’re giving you this and no more.” So the itemized list meant nothing. And this included using that super expensive Da Vinci Robot and everything.

Consider that the Villages Health System was upcoding, but it was also struggling with the fact that most of its patients are on Medicare or Medicare Advantage Plans, so it can be hard to pay the bills.

Remember, this is Chapter 11 bankruptcy. The company isn’t broke. It’s just trying to get some space and time and protection from creditors to readjust and survive. Those buildings and services will still be there.

[golfing eagles]

Originally Posted by drducat

What is concerning is the lack of movement with the negotiations with DOJ and CMS. The penalties involved are could exceed $500 million to a billion alone...time will tell. The we have United stirring the pot also. The rush needed is to maintain the assets ( patients) will leave during next Medicare Advantage sign up period.

Do we even know if the $361 million number being floated already includes interest and penalties?

And do we know what's the level of involvement of DOJ, if any????

[Joecooool]

The family will make a golden statue, and this will all go away.

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

[TomSpasm]

I will say that I was always amazed at the number of issues documented, sometimes the same issue documented more than once, on my Villages Health records, making it seem like I was a total wreck when I was actually doing very well.

[biker1]

I am no longer a patient of The Villages Health (PCP) because I had to leave when I turned 65 and did not opt for a Medicare Advantage Plan. Otherwise, I would still be a patient as I was happy with my PCP. It isn't clear to me that a significant number of people will leave during the next Medicare Advantage open season. Since you pretty much need a PCP for Medicare Advantage, I guess some people might think that the whole operation will collapse and I better leave now and find a new PCP before the onslaught of people looking for new PCPs. I suspect most people will stay the course and continue with The Villages Health until forced to make a change.

Originally Posted by drducat

What is concerning is the lack of movement with the negotiations with DOJ and CMS. The penalties involved are could exceed $500 million to a billion alone...time will tell. The we have United stirring the pot also. The rush needed is to maintain the assets ( patients) will leave during next Medicare Advantage sign up period.

[Rainger99]

Originally Posted by golfing eagles

Simple, 2 letters----AI

Again, AI is not an authoritarian source, it is a computer program, and I stand by my post----garbage in, garbage out. Not in all cases, but how can we know the difference?

AI may not be authoritative - but the website that has all of the TVH bankruptcy filing uses AI to summarize the documents.

And major companies are spending billions to develop AI. There must be something there!

[Jerry101]

Originally Posted by dewilson58

My barber's ex-wife's sister's mechanic knows more than AI.

I'll wait for a good source.

… does the mechanic work on golf carts?!?!? Will he come to my home?!?!? 🏡

[Rainger99]

Originally Posted by golfing eagles

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.

So, bottom line, I don't know, no one posting on TOTV knows,

Thanks for the explanation. However, you mentioned a new term - ACO which is an Accountable Care Organization. I had never heard of that term until your post so I had to google it.

How does that affect payments from Medicare or UHC??

[golfing eagles]

Originally Posted by Rainger99

AI may not be authoritative - but the website that has all of the TVH bankruptcy filing uses AI to summarize the documents.

And major companies are spending billions to develop AI. There must be something there!

Of course there's something there-----$$$$$

Now, is the product all it's cracked up to be? We'll see. But for now it's just regurgitating bits and pieces of an internet search and piecing it together in a nice package with a bow. But is it accurate? Depends. Again, garbage in, garbage out.

As far as spending billions in R&D, I give you the Edsel, Solyndra and Betamax

[Justputt]

Originally Posted by golfing eagles

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.

The wording below by Luria is vague enough "did not appear to be supported by a sufficiently documented clinical basis" that this could be more about a lack of documentation than incorrect entries. We won't know until there are more details presented. I also wonder how much this has to do with the changes made in 2018, 2021, etc. regarding documentation and whether the entire staff kept up with the changes. I know from nearly 40 years in radiation oncology there are more than a small number of people that have different options on coding matters.
Outpatient E/M Coding Simplified | AAFP

Lastly, in the physician groups I've worked with, they not only selected the ICD code, but they also itemized the codes that would be charged (both for pre-auth and giving the patient their good faith estimates for care) as well as dictated the documentation justifying all charges.

"TVH Chief Restructuring Officer Neil Luria said in a July 3 court filing that last year the company hired outside law firms and FTI Consulting Inc. to evaluate the accuracy of the health-care provider’s coding and to investigate any potential over-payments related to Medicare.

That investigation “identified codes TVH submitted that did not appear to be supported by a sufficiently documented clinical basis,” Luria said. The inquiry also identified amendments to patient medical records “appear to have been inconsistent with [the Centers for Medicare and Medicaid Services] guidance and based on a misunderstanding of the relevant guidance on medical record amendments, including when it is appropriate to amend a patient record more than 90 days after an encounter,” he said."

[golfing eagles]

Originally Posted by Rainger99

Thanks for the explanation. However, you mentioned a new term - ACO which is an Accountable Care Organization. I had never heard of that term until your post so I had to google it.

How does that affect payments from Medicare or UHC??

It defines which entities are taking the risk and what set of Draconian rules they must follow. I believe they in turn have to pay the subspecialty consults out of their own pocket (part of the assumed risk) This is one reason (hypothetically) that they are unhappy about what a certain practice was (over)charging them for services rendered.

[Ponygirl]

I am so sorry to ask this perhaps dumb question

So TVH did not accept Medicare patients then shouldn’t they be charging the private MA insurers for patient care not Medicare

I apologize in advance if this is a ridiculous question