[golfing eagles]

Originally Posted by Justputt

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."

Now that post I pretty much agree with. And therein lies the problem---rules and guidelines that are subject to interpretation. Always a formula for problems. When you get caught driving 50 in a 35 zone, the facts are the facts. When the law specifies a mandatory $300 fine, that's it. But when you use the ICDM-10 code for "former smoker", it opens a whole can of worms---how many years smoking?, how long ago did they quit?, how many packs/day?, any COPD?, any thin section chest CT indicated?, how often?. And they key question: Was it "documented". Bottom line: a thousand thing happen in a routine office visit and nobody can "document" them all, which leads to the secondary issue----the idiotic assertion forced on the medical profession by bureaucrats, lawyers and insurance companies---if it wasn't written, it didn't happen. NONSENSE. I shaved this morning. I didn't write it down, so therefore I didn't shave???

So, bottom line, all the hoopla comes down to who wrote what, who interpreted which guideline correctly, which reviewers and bureaucrats are involved and whether or not there was any intent involved.

Everyone seems to want a crucifixion, except maybe the people who are alive and well today because of TVH.

[Rainger99]

Originally Posted by 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

I have the same question. I can’t figure out why Medicare was overcharged. It seems that the advantage insurers were the ones that were overcharged. Although no one has explained whether increasing RAF scores increases payments to UHC or to TVH of to both.

[Rainger99]

I contacted UHC to get my RAF score and they told me to contact TVH. I contacted TVH and they told me that they don’t calculate RAF scores. I have not contacted Medicare but google says that they don’t tell you your score!

I am in excellent health. Yearly physical and I see a dermatologist about twice a year (although my wife thinks I have an unhealthy obsession with the internet).

I think I should be a 1 RAF (or lower) but if they don’t tell me the score, how can I know if I am being upcoded?

Does anyone know how to get an RAF score?

[Bill14564]

Originally Posted by Rainger99

I contacted UHC to get my RAF score and they told me to contact TVH. I contacted TVH and they told me that they don’t calculate RAF scores. I have not contacted Medicare but google says that they don’t tell you your score!

I am in excellent health. Yearly physical and I see a dermatologist about twice a year (although my wife thinks I have an unhealthy obsession with the internet).

I think I should be a 1 RAF (or lower) but if they don’t tell me the score, how can I know if I am being upcoded?

Does anyone know how to get an RAF score?

Honest question that should require some introspection: What would you do with the score if you had it?

Would you tell Medicare that they recorded it incorrectly?
Would you tell your MA plan that they calculated it incorrectly?
Would you tell your physicians that they documented (coded) your care incrorrectly?
Are you qualified to do any of the above?

You get a yearly physical and see a dermatologist twice a year. I get a yearly physical but don't see a dermatologist at all. Given that you visit an office three times as often as I do (or more if you have to contact the PCP for the dermatologist referral) shouldn't your score be higher than mine? I honestly don't know the answer to that which is why I would not think to ask about my score.

[golfing eagles]

Originally Posted by Rainger99

I contacted UHC to get my RAF score and they told me to contact TVH. I contacted TVH and they told me that they don’t calculate RAF scores. I have not contacted Medicare but google says that they don’t tell you your score!

I am in excellent health. Yearly physical and I see a dermatologist about twice a year (although my wife thinks I have an unhealthy obsession with the internet).

I think I should be a 1 RAF (or lower) but if they don’t tell me the score, how can I know if I am being upcoded?

Does anyone know how to get an RAF score?

No. But let me pose this question: Is anyone paying more, OUT OF POCKET, based upon a higher RAF??? Because under such a system, I want way more than a safe driver discount since I have never been in an accident in 50 years of driving. I want cheaper beer since I don't abuse it. I want zero school tax since I don't have kids in schools. Etc, etc.

Bottom line, this is a very complex (and unnecessary) system that basically functions as an employment vehicle for thousands of petty functionaries in the Federal Government. So no one should counter that they are paying more because of so-called "fraud" (which isn't the case with TVH) when they are supporting the salaries of thousands of useless workers who nitpick medical records that they couldn't possibly understand to justify their own existence. They will ALWAYS find something. Sort of like they phrase "I'm here from OSHA and I'm here to help". Get your checkbook ready if you ever hear that.

[golfing eagles]

Originally Posted by Bill14564

Honest question that should require some introspection: What would you do with the score if you had it?

Would you tell Medicare that they recorded it incorrectly?
Would you tell your MA plan that they calculated it incorrectly?
Would you tell your physicians that they documented (coded) your care incrorrectly?
Are you qualified to do any of the above?

You get a yearly physical and see a dermatologist twice a year. I get a yearly physical but don't see a dermatologist at all. Given that you visit an office three times as often as I do (or more if you have to contact the PCP for the dermatologist referral) shouldn't your score be higher than mine? I honestly don't know the answer to that which is why I would not think to ask about my score.

Exactly! It is useless, extraneous information for the medical consumer that really doesn't involve or impact them. I doubt that CMS, an MA plan, or TVH would waste time and resources to have a method of informing them of a score that really isn't much of their business in the first place.

[BrianL99]

Originally Posted by Ken D.

So, who owns Talk of The Villages platform?

It's not very hard to find that information, but I doubt the Moderators would find it appropriate for discussion on here.

[HappyTraveler]

Originally Posted by BrianL99

It's not very hard to find that information, but I doubt the Moderators would find it appropriate for discussion on here.

Why not? It shouldn't be a secret. So, spill names, please.

[Rainger99]

Originally Posted by Bill14564

Honest question that should require some introspection: What would you do with the score if you had it?

Would you tell Medicare that they recorded it incorrectly?
Would you tell your MA plan that they calculated it incorrectly?
Would you tell your physicians that they documented (coded) your care incrorrectly?
Are you qualified to do any of the above?

You get a yearly physical and see a dermatologist twice a year. I get a yearly physical but don't see a dermatologist at all. Given that you visit an office three times as often as I do (or more if you have to contact the PCP for the dermatologist referral) shouldn't your score be higher than mine? I honestly don't know the answer to that which is why I would not think to ask about my score.

The main reason is curiosity. I am curious to find out how healthy Medicare has me coded. I think I am in fantastic health but I would like to know if Medicare agrees with me. I would expect a less than 1.0 so if it were significantly higher than 1, I might ask Medicare to review my records to see if they are accurate. I believe in transparency.

Don't you like to know your credit score? It used to be difficult to get your credit rating, but it is much easier now. That is important because if there are mistakes, it really impacts you. Several years ago, I checked my credit rating and they had someone with a similar name but it wasn't me. I asked them to change it.

A week ago, I had never heard of RAF scoring. However, since RAF rating appears to be one of the major factors in TVH bankruptcy, I am concerned that my RAF might be inflated.

Also, I am in Advantage right now and I am considering moving to Medicare next year. However, if I have an elevated RAF score, it might prevent me from transferring.

I found this article on the internet. Check out how complicated it is!!

Diagnosis Coding for Value-Based Payment: A Quick Reference Tool | AAFP

[Bill14564]

Originally Posted by Rainger99

The main reason is curiosity. I am curious to find out how healthy Medicare has me coded. I think I am in fantastic health but I would like to know if Medicare agrees with me. I would expect a less than 1.0 so if it were significantly higher than 1, I might ask Medicare to review my records to see if they are accurate. I believe in transparency.

Don't you like to know your credit score? It used to be difficult to get your credit rating, but it is much easier now. That is important because if there are mistakes, it really impacts you. Several years ago, I checked my credit rating and they had someone with a similar name but it wasn't me. I asked them to change it.

A week ago, I had never heard of RAF scoring. However, since RAF rating appears to be one of the major factors in TVH bankruptcy, I am concerned that my RAF might be inflated.

Also, I am in Advantage right now and I am considering moving to Medicare next year. However, if I have an elevated RAF score, it might prevent me from transferring.

I found this article on the internet. Check out how complicated it is!!

Diagnosis Coding for Value-Based Payment: A Quick Reference Tool | AAFP

My credit score affects my wallet, my RAF does not.
Things that affect my credit score are objective, things that affect my RAF are subjective. I can argue one but I’m not qualified to argue the other.

This is beyond what I have looked into but I believe RAF, a number used for reimbursing MA plans, has no meaning on “regular” Medicare.

[Rainger99]

Originally Posted by Bill14564

My credit score affects my wallet, my RAF does not.
Things that affect my credit score are objective, things that affect my RAF are subjective. I can argue one but I’m not qualified to argue the other.

This is beyond what I have looked into but I believe RAF, a number used for reimbursing MA plans, has no meaning on “regular” Medicare.

It might not affect your wallet, but if they have you listed as a smoker and you are not, would you want to correct that?

And it might affect Medicare's wallet - which we are all paying for.

It would be nice if the doctor (or insurance company or medicare) showed you the records that they based your score on so that you could have some idea if they are accurate.

[Bill14564]

Originally Posted by Rainger99

It might not affect your wallet, but if they have you listed as a smoker and you are not, would you want to correct that?

And it might affect Medicare's wallet - which we are all paying for.

It would be nice if the doctor (or insurance company or medicare) showed you the records that they based your score on so that you could have some idea if they are accurate.

No, I would not care (primarily because I would not know).

My being listed as a smoker would be a very, very small potato seed in the grand scheme of things. It may or may not be caught in an audit but the cost of finding and correcting it would be far more than the cost of the incorrect entry.

[Wrhobson]

Originally Posted by idlewild

It probably will be - or deleted - but I hope not. I'm not trying to stir up controversy here, and everyone should be entitled to his/her own opinion.

While the Villages is a great place to live and the Developer has provided a wonderful community for many - and should be handsomely rewarded for it - my personal view is that they're also taking advantage of some "Midwest nice" naivety and incredibly bullying, often to their own customers and advocates (SEE: Bogus Drone Cease and Desist Letters). And when a party owes $300M to the federal government which is only self-reports months after a newly formed Department of Government Efficiency gains "access to key data systems within Health and Human Services, including Medicare and Medicaid records, as it looks for waste and fraud in federal health spending" and then sells off a major asset before filing for bankruptcy protection, that's a bit of smoke worth investigating - especially when it may have longer term impact on both home values and the quality/cost of maintenance services ongoing.

Again, just my two cents.

So, they have somehow "misplaced" $361 million? That may be an indication of the altitude this family lives in.

[tophcfa]

Originally Posted by golfing eagles

No. But let me pose this question: Is anyone paying more, OUT OF POCKET, based upon a higher RAF???

I think the answer would be indirectly, it would be taxpayers like you and me???

[ScottFenstermaker]

Medicare law firm soliciting business in The Villages. I wonder if TVHS doctors are starting to lawyer up. Click here:

federal-lawyer.com | 520: Web server is returning an unknown error