[Babubhat]

There is no purpose for the judge in bankruptcy to say it is solvent. no vendor will ever do business with them again. Judge function is to clean this up as quickly as possible. Lawyers clean up. The rest get the crumbs

[GoldenBoy]

If the Family is found liable for this fraud should Villagers start preparing for increase in amenities fees to go up to cover the Familiy's payback?

[dewilson58]

Originally Posted by GoldenBoy

If the Family is found liable for this fraud should Villagers start preparing for increase in amenities fees to go up to cover the Familiy's payback?

Been here 5 years???......................amenities fees do not go to the family (except new areas for a short period of time)

[biker1]

FYI, the amenities' fee goes up by the CPI on the anniversary of when your house first sold. Regarding who gets the funds, see the previous post.

Originally Posted by GoldenBoy

If the Family is found liable for this fraud should Villagers start preparing for increase in amenities fees to go up to cover the Familiy's payback?

[golfing eagles]

Originally Posted by GoldenBoy

If the Family is found liable for this fraud should Villagers start preparing for increase in amenities fees to go up to cover the Familiy's payback?

What "fraud"? Again, neither CMS nor DOJ is using that term, only posters on TOTV.

[Babubhat]

Originally Posted by GoldenBoy

If the Family is found liable for this fraud should Villagers start preparing for increase in amenities fees to go up to cover the Familiy's payback?

Fraud is a very high standard to prove. These matters are usually settled. Appeals process can go on for a decade

[ThirdOfFive]

Originally Posted by golfing eagles

I'll amplify the first part----their doctors did not know there was overbilling. While I doubt it, somebody higher on the food chain may have been in a position to manipulate the billing.

Second---what do you think medical practices spend their money on? It's not jet skis and ice cream floats. There is no conjecture about what medical practice expenses consist of. The unknown factor is any potential distributions, but I addressed that.

Third--"uneducated/careless in their responsibilities"---almost too inane to deserve a response, but....if they believe they are billing correctly, and if their consultants believe they are billing correctly, how are they careless? And speaking of conjecture, how do YOU know other practices aren't in the same boat????

PS: I have no affiliation with TVH, I've been retired for over 10 years

You seem like you have more familiarity with this topic than most. So...

This is a big deal (and rightfully so) to people living in TV. And $360 million more or less is a LOT of money. But looking at things objectively it is (relatively speaking) peanuts. Most estimates place the amount of Medicare fraud occurring in America at the rate of $60 BILLION dollars per year. We don't know how much if any of this $360 million was intentionally fraudulent, and I am sure that it spanned years. But even if it was fraudulent and occurred all within one year it would still amount to barely 1/2 of 1% of the total Medicare fraud for that year.

OK. Given the above, what are the safeguards against fraud, if any, on the other end of the money pipeline? Aren't there watchdogs on the Medicare end of things? $360 million relatively speaking might be peanuts but $60 billion is huge. Is that particular segment of our government so clueless that $60 billion can just be explained by ignorance? Politely speaking, that possibility beggars the imagination. Or is there even the faintest possibility that fraud may be being committed on both ends?

Your thoughts appreciated.

[BrianL99]

Originally Posted by ThirdOfFive

You seem like you have more familiarity with this topic than most. So...

This is a big deal (and rightfully so) to people living in TV. And $360 million more or less is a LOT of money. But looking at things objectively it is (relatively speaking) peanuts. .

$360 Million seems like a huge number.

Over 4 years, it comes to $90M/year.

On a per patient basis, it's $1600/year.

Given the cost of medical care these days, that's probably about 6 minutes in an Operating Room, per patient.

6 minutes here, 6 minutes there ... pretty soon we're talking about real money.

[golfing eagles]

Originally Posted by ThirdOfFive

You seem like you have more familiarity with this topic than most. So...

This is a big deal (and rightfully so) to people living in TV. And $360 million more or less is a LOT of money. But looking at things objectively it is (relatively speaking) peanuts. Most estimates place the amount of Medicare fraud occurring in America at the rate of $60 BILLION dollars per year. We don't know how much if any of this $360 million was intentionally fraudulent, and I am sure that it spanned years. But even if it was fraudulent and occurred all within one year it would still amount to barely 1/2 of 1% of the total Medicare fraud for that year.

OK. Given the above, what are the safeguards against fraud, if any, on the other end of the money pipeline? Aren't there watchdogs on the Medicare end of things? $360 million relatively speaking might be peanuts but $60 billion is huge. Is that particular segment of our government so clueless that $60 billion can just be explained by ignorance? Politely speaking, that possibility beggars the imagination. Or is there even the faintest possibility that fraud may be being committed on both ends?

Your thoughts appreciated.

And some other estimates are as high as $105 billion. But I think we need to clarify what is being loosely thrown around as "fraud". I believe the definition of fraud is intentional misrepresentation (legal dictionaries agree). If I believe my SUV is in good working order and sell it to you, and it turns out it's a lemon, it is NOT fraud. If I knew and concealed it, THEN it is fraud. If I believe I correctly documented a patient visit as a 99214, but CMS disagrees, IT IS NOT FRAUD. It's only if I knew it didn't meet the criteria and billed that code anyway that I committed fraud.

Now that the definition is clear (sorry to the hundreds of posters that are accusing TVH of "fraud"), there is the question of what is included in that $60-105B estimate:
First there is outright fraud, medical practices that were set up for no other purpose than to bill Medicare millions for unnecessary work or services that were never performed. These are usually fly by night clinics owned by somebody with a bogus medical degree from the Caribbean that pays winos and homeless people cash and a bottle of thunderbird to come to their clinic and have "tests", or just say they did. They are usually gone by the time CMS catches on, and doing the same thing under a different name. California, Arizona and Florida are notorious for these.

Then there is gray zone "fraud". Coding aggressively but not necessarily having the documentation to support the submitted codes. If this is intentional it might be fraud, but like I said, it's a gray zone. And believe me, I can turn even a 3-minute visit for a sore throat into a 99215 (highest level of office visit) if I was so inclined. How is that possible? Because it is no longer important what you doctor does, only what he writes. Thank the bean counters at CMS and insurance co. as well as lawyers for that one. The result, for some less scrupulous physicians, is that they would rather spend 2 minutes with the patient and 10 minutes documenting that visit--far more lucrative.

And then there is "overbilling" or "miscoding" or "computer error" or "misinterpretation of ICDM-10 and CPT" or whatever you want to call it. This is devoid of intent, and also subject to interpretation of the vague guidelines.

So, what are the safeguards?
For the fraudulent practices, it involves CMS and DOJ identifying them, usually because their billing is way more than similar sized legitimate practices. But again, they have a tendency to disappear off the grid until they re-emerge elsewhere.

For the aggressive coders, CMS knows the bell curve of CPT E&M charges and can identify anomalies. They would then ask the practice to submit 25 or 50 progress notes for review to see if the documentation supports the coding, and pay the practice a "visit" if they are out of compliance. For one group of cardiovascular surgeons in Syracuse, that visit was by the FBI with M-16s in full body armor while their waiting room was packed with their patients.

For the other 95% of practices that wants to play by the rules, it starts with internal chart review. In our group of 6, we just reviewed each other's notes and coding. In large practices like TVH, they have outside consultants that perform that task. And this is where the TVH case get murky. (Hypothetically), those outside consultants told TVH that they were in compliance with the rules. Also, hypothetically, later reviewers disagreed. And like all practices they also had to send CMS charts to review periodically, so I don't understand how any "overbilling" didn't come to light years ago. Now, and to appease certain others on TOTV, I will term the following "conjecture". The chart review at CMS was conducted by low level staff who either didn't catch it or more likely also thought it was legitimate. But with all the hoopla with Humana and UHC as well as a very large number being thrown around, it caught the attention of a higher level bureaucrat, and probably one with even higher ambitions.

From my experience, if CMS finds what is overbilling in their opinion, you can appeal or just give them some money back. But I don't think anyone wants to try to give $361M back. Of course, we don't know exactly what period of time might be involved, if that number is accurate, and whether or not it includes interest and penalties, which would be negotiable.

I just want to reiterate that no one on TOTV, including myself, knows what happened. And it will take time for this to all settle out.

In the meantime, I agree we are in a mess. TVH has 50,000 patients. Already at least 2 doctors are trying to leave. We don't have enough physicians for our population as it is, and any mass exodus will spell trouble. And not only for patients of TVH---those patients will start flooding other practices, and those that can't find a new PCP will end up in urgent care and ER's. In turn, anyone with a real emergency may be walking into a logjam. So let's hope they get acquired or bailed out before it's too late and table the recriminations until we know the population will be cared for.

[Babubhat]

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.

Making an unfounded claim can get you sued for slander. Hiding behind a screen name will not protect you.

[Kerry Azz]

Originally Posted by idlewild

From AI deep research:

Potential Liability of Jennifer Parr & the Morse Family in The Villages Health Overbilling Case

Ownership Structure and Control of The Villages Health System: Bankruptcy filings confirm that The Villages Health System, LLC (TVHS) is closely held and controlled by the Morse family (developers of The Villages). In the Chapter 11 petition, Jennifer L. Parr (a member of the Morse family) is identified as a Manager of The Villages Health Holding Company, LLC – the majority owner of TVHS. Similarly, Mark G. Morse (Jennifer’s brother and a principal in the family business) signed the corporate resolutions both as a Board Member of TVHS and as a Manager of the holding company. These documents make clear that the same individuals behind The Villages development also own and control TVHS, which a court filing emphasizes is a “closely-held family-owned company." In short, the Morse family – through The Villages Health Holding Co. – has majority ownership and operational control over the health system.

Financial Relationship with The Villages Development: The bankruptcy case documents and related disclosures shed light on the intertwined financial relationship between TVHS and the Morse family’s development enterprise. UnitedHealthCare (UHC), the Medicare Advantage insurer for most TVHS patients, revealed in a court objection that it had a special arrangement with The Villages’ owners: UHC prepaid for exclusive rights to use The Villages’ branding and marketing via an affiliate of The Villages (the developer). This indicates that the Morse family’s companies benefited financially from TVHS’s operations by licensing the community’s name and logo. Additionally, public reports suggest that many of the clinics and facilities were built by The Villages’ developer and then leased to TVHS, meaning the health system was effectively paying rent to its owners’ affiliated real estate business. Such self-dealing arrangements underscore how deeply enmeshed the health system’s finances are with the Morse family’s broader business interests.

Disclosures of Overbilling and Alleged Responsibility: In late 2024, The Villages Health System self-reported a massive Medicare billing problem: an internal investigation found that TVHS had logged patient diagnoses that “were not clinically supported or otherwise did not meet Medicare coding and payment guidance,” leading to hundreds of millions in improper payments. By the time of the Chapter 11 filing (July 3, 2025), a preliminary analysis indicated overpayments of at least $350–361 million to TVHS. Court filings show the company openly acknowledged these errors and even notified patients about the issue. Notably, UnitedHealthCare’s filing goes further in characterizing blame: it states that TVHS “admitted to the submission of incorrect information” to insurers and has a “record of corporate misbehavior." UHC points out that the same individuals who own The Villages (the Morse family) also own and control TVHS, insinuating that the development owners were in a position to direct or permit the practices that led to the overbilling. In a striking assertion, UHC’s court submission warns that the Debtor’s officers, directors, and owners (i.e. the Morse family and Jennifer Parr) now “face hundreds of millions of dollars of liability” due to the false Medicare information submitted. This implies that beyond the company’s liability, those in control could be held personally or corporately responsible for the $361 million overbilling, at least in UHC’s view.

Potential Legal Exposures for Jennifer Parr and the Morse Family
Civil Liability and DOJ Inquiry: The bankruptcy documents make clear that federal authorities are involved. TVHS’s filings note it has been in communication with the U.S. Department of Justice (Civil Division) and the HHS Office of Inspector General regarding the overpayments. The company is working “toward a resolution with the U.S. government” to repay the approximately $361 million, which will likely include significant financial penalties. This suggests a potential False Claims Act civil action or similar, which can impose treble damages. While no lawsuit naming individual executives has been filed as of the filings, UHC’s allegation that the owners themselves face liability indicates that Jennifer Parr, Mark Morse, and other insiders could be targets of civil claims – either by the government under the False Claims Act (if they knew about or directed the false billing) or by private parties (such as UHC seeking indemnification). In sum, the civil exposure is substantial, and the DOJ’s involvement confirms that a federal investigation is ongoing (even if currently civil in nature). Any eventual settlement or judgment could potentially seek guarantees or contributions from those in control if misconduct is proven.

Criminal Liability: No direct evidence of a criminal investigation appears in the bankruptcy filings to date – references to DOJ have been explicitly to its civil division. The overbilling has been officially described as “erroneous” or based on misunderstandings of coding guidance, rather than an intentional fraud, and the company self-disclosed the issue. These factors suggest the matter is being handled as a civil regulatory breach. However, the magnitude ($361 million) of the improper claims raises the stakes. If future evidence were to show knowing or willful fraud (for example, if executives pressured clinicians to upcode diagnoses), the Morse family principals could conceivably face criminal health care fraud or false claims charges. So far, there is no indication in the court papers of a criminal referral, but the risk remains if new facts emerge. For now, the legal peril for Parr and the Morse family lies more in civil enforcement (with massive financial and reputational consequences) than in criminal prosecution.

Breach of Fiduciary Duty: As managers and controlling owners of the LLC, Jennifer Parr and the Morse family owed fiduciary duties to the company (and now, in bankruptcy, to its creditors). The court documents do not explicitly accuse them of breaching those duties, but certain facts invite scrutiny. The need to bring in “independent managers” and a new Chief Restructuring Officer to improve compliance after the overbilling was uncovered suggests that previous oversight by insiders was inadequate. If it is shown that the family-controlled board failed to implement proper auditing or compliance controls (allowing the false billing to continue for years), that could be viewed as a breach of their duty of care. Moreover, any self-dealing transactions are a red flag: for instance, if TVHS paid above-market rents or fees to Morse-controlled entities (benefiting the owners while the company racked up liabilities), a creditors’ committee or trustee could argue the insiders breached their duty of loyalty. In the ongoing bankruptcy, stakeholders may investigate whether the owners prioritized their own interests over the company’s solvency. Any such findings could lead to litigation against the Morse family for mismanagement or fiduciary lapses, though no lawsuit of that kind has been filed yet.

Fraudulent Conveyance Concerns: Thus far, the filings have not revealed any specific transfers of assets from TVHS to the owners pre-bankruptcy. However, given the enormous government claim and the family’s control, creditors will likely examine any pre-petition distributions or asset transfers to Morse-family entities. If, for example, significant profits from the overcoding years were upstreamed to The Villages Holding Company or related family trusts, those could be subject to clawback as fraudulent conveyances in bankruptcy (if made when TVHS was insolvent or intended to hinder creditors). Public observers have noted suspicious timing in the Morse family’s financial maneuvers – for instance, a large family-owned asset (a Villages-affiliated bank) was sold not long before the overbilling became public, prompting questions about whether this was done to isolate assets from potential forfeiture or liability. While this is speculative and not documented in the court record, it underscores the concern that any transfer benefiting the owners at the expense of TVHS’s creditors will face scrutiny. The bankruptcy court has strong powers to unwind fraudulent transfers, so if evidence emerges of such transactions, Jennifer Parr and her family could be forced to return funds to the estate.

Department of Justice and Regulatory Actions: In addition to the bankruptcy process, the Morse family must be mindful of parallel government actions. The DOJ civil inquiry (and involvement of HHS OIG) means there is a risk of a False Claims Act case, which could theoretically name individuals (owners or executives) if they were complicit in the false billings. So far, TVHS’s cooperation and self-disclosure may be mitigating factors. Nevertheless, the overbilling is at a scale that has drawn federal attention, and the outcome could include a corporate integrity agreement or other oversight that affects the family’s control over any reorganized health business. If negotiations with DOJ do not resolve the liability, a civil suit could be filed. The Morse family also faces intense scrutiny from private creditors like UHC. UHC’s filings indicate it feels misled and left out, and it may pursue its own legal remedies to recover losses – potentially even alleging fraud or conspiracy involving TVHS leadership. All of these avenues mean Jennifer Parr and her relatives are not shielded simply by putting the company in bankruptcy; their decisions and any knowledge of the overbilling are under the microscope of federal investigators and creditors.

Conclusion
In summary, the bankruptcy documents portray The Villages Health System’s overbilling debacle as a liability largely resting with the company, but they also tie that company inextricably to the Morse family. Jennifer Parr, Mark Morse, and related insiders are documented as the ultimate decision-makers for TVHS, and even the firm’s long-time business partner (UHC) has alleged in court that these owners could personally face “hundreds of millions” in exposure for the false Medicare billings. While no filing to date outright accuses Parr or the Morse family of criminal wrongdoing, the evidence of massive billing irregularities and the close involvement of ownership raise the prospect of significant legal repercussions. They range from civil False Claims Act penalties and DOJ-driven settlements to potential breach of duty or fraudulent transfer claims in the bankruptcy. Any criminal liability would depend on proof of intent and is not asserted so far, but it remains a looming possibility given the scale of the fraud. Going forward, Jennifer Parr and the Morse family will likely be under significant legal pressure: they may need to contribute to any government settlement, justify past transactions, and demonstrate that they did not personally profit from or direct the improper billing. The court filings and exhibits thus far highlight their control over the health system and foreshadow a careful examination of whether that control was misused, making personal or corporate liability a very real concern as this case progresses. Sources: The Villages Health System LLC Chapter 11 Petition & Board Resolutions.


Sources:

The Villages Health Bankruptcy | PDF | Chapter 11 | Unsecured Debt
The Villages Health Bankruptcy | PDF | Chapter 11 | Unsecured Debt

United HealthCare highly suspicious of proposed sale of The Villages Health - **************.com
https://www.**************.com/2025/...llages-health/

Bankruptcy of The Villages Health raises many questions - **************.com
https://www.**************.com/2025/...any-questions/

Villages Health System Sees $350 Million in Medicare Overcharges
Villages Health System Sees $350 Million in Medicare Overcharges

Villages Health company, under fire for Medicare overpayments, files for Chapter 11 bankruptcy
Villages Health company, under fire for Medicare overpayments, files for Chapter 11 bankruptcy

They wanna play the morse family must pay, the family acted together to conspire to commit what we all know was a crime, they should be charged with the RICO ACT! They strong arm the stores and restaurants in the villages and healthcare prosecute them to the max.

[Aces4]

Originally Posted by golfing eagles

And some other estimates are as high as $105 billion. But I think we need to clarify what is being loosely thrown around as "fraud". I believe the definition of fraud is intentional misrepresentation (legal dictionaries agree). If I believe my SUV is in good working order and sell it to you, and it turns out it's a lemon, it is NOT fraud. If I knew and concealed it, THEN it is fraud. If I believe I correctly documented a patient visit as a 99214, but CMS disagrees, IT IS NOT FRAUD. It's only if I knew it didn't meet the criteria and billed that code anyway that I committed fraud.

Now that the definition is clear (sorry to the hundreds of posters that are accusing TVH of "fraud"), there is the question of what is included in that $60-105B estimate:
First there is outright fraud, medical practices that were set up for no other purpose than to bill Medicare millions for unnecessary work or services that were never performed. These are usually fly by night clinics owned by somebody with a bogus medical degree from the Caribbean that pays winos and homeless people cash and a bottle of thunderbird to come to their clinic and have "tests", or just say they did. They are usually gone by the time CMS catches on, and doing the same thing under a different name. California, Arizona and Florida are notorious for these.

Then there is gray zone "fraud". Coding aggressively but not necessarily having the documentation to support the submitted codes. If this is intentional it might be fraud, but like I said, it's a gray zone. And believe me, I can turn even a 3-minute visit for a sore throat into a 99215 (highest level of office visit) if I was so inclined. How is that possible? Because it is no longer important what you doctor does, only what he writes. Thank the bean counters at CMS and insurance co. as well as lawyers for that one. The result, for some less scrupulous physicians, is that they would rather spend 2 minutes with the patient and 10 minutes documenting that visit--far more lucrative.

And then there is "overbilling" or "miscoding" or "computer error" or "misinterpretation of ICDM-10 and CPT" or whatever you want to call it. This is devoid of intent, and also subject to interpretation of the vague guidelines.

So, what are the safeguards?
For the fraudulent practices, it involves CMS and DOJ identifying them, usually because their billing is way more than similar sized legitimate practices. But again, they have a tendency to disappear off the grid until they re-emerge elsewhere.

For the aggressive coders, CMS knows the bell curve of CPT E&M charges and can identify anomalies. They would then ask the practice to submit 25 or 50 progress notes for review to see if the documentation supports the coding, and pay the practice a "visit" if they are out of compliance. For one group of cardiovascular surgeons in Syracuse, that visit was by the FBI with M-16s in full body armor while their waiting room was packed with their patients.

For the other 95% of practices that wants to play by the rules, it starts with internal chart review. In our group of 6, we just reviewed each other's notes and coding. In large practices like TVH, they have outside consultants that perform that task. And this is where the TVH case get murky. (Hypothetically), those outside consultants told TVH that they were in compliance with the rules. Also, hypothetically, later reviewers disagreed. And like all practices they also had to send CMS charts to review periodically, so I don't understand how any "overbilling" didn't come to light years ago. Now, and to appease certain others on TOTV, I will term the following "conjecture". The chart review at CMS was conducted by low level staff who either didn't catch it or more likely also thought it was legitimate. But with all the hoopla with Humana and UHC as well as a very large number being thrown around, it caught the attention of a higher level bureaucrat, and probably one with even higher ambitions.

From my experience, if CMS finds what is overbilling in their opinion, you can appeal or just give them some money back. But I don't think anyone wants to try to give $361M back. Of course, we don't know exactly what period of time might be involved, if that number is accurate, and whether or not it includes interest and penalties, which would be negotiable.

I just want to reiterate that no one on TOTV, including myself, knows what happened. And it will take time for this to all settle out.

In the meantime, I agree we are in a mess. TVH has 50,000 patients. Already at least 2 doctors are trying to leave. We don't have enough physicians for our population as it is, and any mass exodus will spell trouble. And not only for patients of TVH---those patients will start flooding other practices, and those that can't find a new PCP will end up in urgent care and ER's. In turn, anyone with a real emergency may be walking into a logjam. So let's hope they get acquired or bailed out before it's too late and table the recriminations until we know the population will be cared for.

Possibly a billion dollars in false payments..yeah, couldn't be any fraud anywhere. I'd like to see a computerized tracking device for the care of Medicare patients. Hand the tracker to the patient for when they enter the office, time the MA or nurse spends in the room and actual time Dr. is in the room.

I had a pretty good Dr. but this Dr.'s. caseload is in overload. The last two yearly visits had me waiting in the room for 40 minutes after the scheduled appt., I get that. But then this Dr. spent 7-8 minutes with me for the yearly followup. I get that, the Dr. is behind. But when I see it come through Medicare charged as a long visit, it torques my jaw. The Dr. should be paying me for wasting my time and then overbilling.

[golfing eagles]

Originally Posted by Aces4

Possibly a billion dollars in false payments..yeah, couldn't be any fraud anywhere. I'd like to see a computerized tracking device for the care of Medicare patients. Hand the tracker to the patient for when they enter the office, time the MA or nurse spends in the room and actual time Dr. is in the room.

I had a pretty good Dr. but this Dr.'s. caseload is in overload. The last two yearly visits had me waiting in the room for 40 minutes after the scheduled appt., I get that. But then this Dr. spent 7-8 minutes with me for the yearly followup. I get that, the Dr. is behind. But when I see it come through Medicare charged as a long visit, it torques my jaw. The Dr. should be paying me for wasting my time and then overbilling.

The usual billing codes have nothing to do with time. Physicians do not punch a time clock. There is no such thing as a "long" visit. The level of coding is determined by the extent of the medical history and physical exam along with the complexity of medical management. So basically, unless you have the progress note, know the E&M codes, and know how to apply them, you have absolutely no basis upon which to accuse him of "overbilling"

PS: and now we're up to $1 billion in "false" charges? Inflation?????

[Aces4]

Originally Posted by golfing eagles

The usual billing codes have nothing to do with time. Physicians do not punch a time clock. There is no such thing as a "long" visit. The level of coding is determined by the extent of the medical history and physical exam along with the complexity of medical management. So basically, unless you have the progress note, know the E&M codes, and know how to apply them, you have absolutely no basis upon which to accuse him of "overbilling"

PS: and now we're up to $1 billion in "false" charges? Inflation?????

Yeah, may be slightly over a billion... follow all the threads regarding this.

Then why does Medicare declare it to be a "long visit"? The extent of the visit was minimal, ten seconds of thyroid neck check, (didn't even have to swallow water this time), and was advised to reschedule in a year. That is my basis. At this age I am well aware of time allotted and the extent of service. The Dr. is very familiar with my history and, honestly, was more determined to get back on schedule than my office visit. You can schmooz it over and pad the services but they were so basic it was ridiculous. Maybe things have changed since you hung up your smock. AI: Yes, Medicare does distinguish between different levels of office visits, including "long" office visits, for payment purposes. Here's how Medicare addresses this: Office Visit Codes: Medicare uses Evaluation and Management (E/M) codes to classify office visits based on the level of complexity, medical decision-making, or the total time spent during the encounter. Prolonged Services: For visits that extend beyond the maximum time allocated for a standard Level 5 office visit (99205 for new patients and 99215 for established patients), Medicare utilizes a specific add-on code, G2212. G2212 - The Medicare Prolonged Services Code: This code is used when the total time spent by the physician or qualified healthcare professional on the date of service exceeds the maximum time for the highest level E/M visit (99205 or 99215) by at least 15 minutes. It is billed in 15-minute increments. Total time includes all the time spent by the reporting practitioner on the date of service, including face-to-face time and time spent on activities like chart review, documentation, communication with other professionals, etc., according to the American Academy of Family Physicians | AAFP Medicare's guidelines for prolonged services differ from the AMA's CPT code 99417, which some other payers might utilize. In essence, Medicare distinguishes longer office visits by requiring the use of a prolonged services code (G2212) in addition to the standard E/M code when the visit duration surpasses a specific threshold, ensuring appropriate reimbursement for extended care.

[golfing eagles]

Originally Posted by Aces4

Yeah, may be slightly over a billion... follow all the threads regarding this.

Then why does Medicare declare it to be a "long visit"? The extent of the visit was minimal, ten seconds of thyroid neck check, (didn't even have to swallow water this time), and was advised to reschedule in a year. That is my basis. At this age I am well aware of time allotted and the extent of service. The Dr. is very familiar with my history and, honestly, was more determined to get back on schedule than my office visit. You can schmooz it over and pad the services but they were so basic it was ridiculous. Maybe things have changed since you hung up your smock. AI: Yes, Medicare does distinguish between different levels of office visits, including "long" office visits, for payment purposes. Here's how Medicare addresses this: Office Visit Codes: Medicare uses Evaluation and Management (E/M) codes to classify office visits based on the level of complexity, medical decision-making, or the total time spent during the encounter. Prolonged Services: For visits that extend beyond the maximum time allocated for a standard Level 5 office visit (99205 for new patients and 99215 for established patients), Medicare utilizes a specific add-on code, G2212. G2212 - The Medicare Prolonged Services Code: This code is used when the total time spent by the physician or qualified healthcare professional on the date of service exceeds the maximum time for the highest level E/M visit (99205 or 99215) by at least 15 minutes. It is billed in 15-minute increments. Total time includes all the time spent by the reporting practitioner on the date of service, including face-to-face time and time spent on activities like chart review, documentation, communication with other professionals, etc., according to the American Academy of Family Physicians | AAFP Medicare's guidelines for prolonged services differ from the AMA's CPT code 99417, which some other payers might utilize. In essence, Medicare distinguishes longer office visits by requiring the use of a prolonged services code (G2212) in addition to the standard E/M code when the visit duration surpasses a specific threshold, ensuring appropriate reimbursement for extended care.

Short answer to first question: THEY DON'T. There is no "long visit" There is extent and complexity of visits. Here is the CPT description and documentation requirements for 99215:

What Does CPT Code 99215 Mean?

CPT code 99215 is specifically used to document a comprehensive evaluation and management service for established patients. To qualify for this code, the visit must meet the following criteria:

Comprehensive History: The patient’s history must be well-documented, including a detailed assessment of their medical condition, family history, and social history.
Comprehensive Examination: The physical examination should be thorough, covering all systems related to the patient’s presenting problems.
High Complexity Medical Decision-Making (MDM): The physician must demonstrate a high level of decision-making. This involves analyzing multiple diagnoses, reviewing test results, and determining complex treatment options.

Using this code appropriately ensures that healthcare providers are compensated for the time, effort, and resources required to manage complex patient conditions.

Documentation Requirements for CPT Code 99215
Proper documentation is key to successfully using CPT code 99215. It is essential that the documentation captures all three critical components: history, examination, and decision-making. Here’s a breakdown of what’s required:



Comprehensive History: This must include an extended history of present illness, an extended review of systems (ROS), and a complete past, family, and social history (PFSH). The history should be documented thoroughly to reflect the patient’s complex health status.
Comprehensive Examination: The physician must document a detailed examination of at least eight organ systems or body areas. All pertinent findings, whether normal or abnormal, should be included in the documentation.
High Complexity MDM: The documentation must show a high level of decision-making, including multiple management options, a thorough review of test results, and an assessment of patient risks and benefits for each treatment option considered.

Please point out, right from this excerpt from CPT, the word "long"

Now, as an aside, CPT does make statements that ARE NOT PART OF THE CRITERIA such as "this visit will typically take a physician xxx minutes to complete", which is a suggestion/guideline, but not part of the requirements. Also, when the strict documentation guidelines do not fit the service, there is a way to document time spent---the most obvious example is psychiatry where 50 minutes is spent "just talking", but bedside management in an ICU setting can also be billed by time.

Two other points that I will try to make politely:

1) "Yeah, may be slightly over a billion... follow all the threads regarding this."

Yep, social media, the place to get all the facts. If it's on the internet, it must be true???

2) "ten seconds of thyroid neck check, (didn't even have to swallow water this time), and was advised to reschedule in a year. That is my basis."

OK, that's your basis. My basis is using, documenting and reviewing these codes for 35 years. Please don't even think about equating the two.