[golfing eagles]

Originally Posted by BrianL99

Someone in the medical business would know better, but I believe the "coding" and billing process is completely different for Advantage insurers, vs Supplemental insurers.

Again, just an educated guess ... with a Supplemental Plan, the consumer/patient is more involved in the process, up and through billing. Depending on the specifics of the supposed "computer error", it's likely that it would have been caught sooner with a Supplemental plan ... the billing is more transparent.

Actually, you are more correct than you might think. TVH is paid on a diagnostic complexity per patient per month basis, different from straight Medicare.

[dgoodman]

Originally Posted by tophcfa

Interesting, but not surprising. The fact that they only accepted certain Advantage plans, and no Medigap plans, for primary care immediately raised the hair on the back of my neck that something fishy was going on. As far as I’m aware, they were the only large health care operation in the country serving a predominantly senior citizen population that wouldn’t accept traditional Medicare. My intuitive suspicions aren’t always correct, but apparently it was this time.

It was only for primary care physicians that they only took Medicare Advantage, specialty care physicians accepted standard Medicare Medigap plans.

[golfing eagles]

Originally Posted by Marmaduke

Okay, so this is may be true.
What a shame they didn't have enough business acumen to have an annual audit by certified auditor.
Even small business operations know to check the books. What am I missing Doc?

OK, I'll try to explain what happened (and realize that 99% of previous posts are just speculative BS):

Let's give an example: A patient taking aspirin after previous vascular surgery for say carotid occlusion has easy bruising. It gets coded as "acquired platelet dysfunction", which is exactly what it is. Or is it? Depends on interpretation. So the outside auditors for TVH tell them it is absolutely correct to use that code (Yes, they have continuous outside auditing). Then they get into negotiations with Humana, and Humana says that's wrong, you can't use that code in this instance. So TVH self-reports the discrepancy to CMS and this whole thing begins. There's more to it that I'm not at liberty to discuss, but there was NO INTENT TO DEFRAUD.

[biker1]

My wife, who knows her way around medical insurance after practicing for 40 years, alerted me about an insurance issue. She had gone in for a normal blood draw before an annual wellness visit and they wanted to do a vitals check on her. She declined since she suspected they would code it as an office visit. A month later, I went in for a normal blood draw, and I told them they could skip any vitals check. They said they weren’t doing that any more. Neither one us us has any health issues. Hmmm …

Originally Posted by Normal

This is the same group who asked me 3 questions and called it a “WellnessCheck”. In turn they billed Medicare 160 bucks. I hope they get fried. Follow the money and bust them all!

[Bjeanj]

I am still amazed by those who automatically believe the worst in any situation, and nothing will convince them they are wrong.

[BrianL99]

Originally Posted by golfing eagles

Actually, you are more correct than you might think. TVH is paid on a diagnostic complexity per patient per month basis, different from straight Medicare.

Originally Posted by golfing eagles

A patient taking aspirin after previous vascular surgery for say carotid occlusion has easy bruising. It gets coded as "acquired platelet dysfunction", which is exactly what it is. Or is it? Depends on interpretation. So the outside auditors for TVH tell them it is absolutely correct to use that code (Yes, they have continuous outside auditing). Then they get into negotiations with Humana, and Humana says that's wrong, you can't use that code in this instance.

If there's $360M in over billing, it seems the hammer needs to come down on someone, but it's not clear from your characterization, whether it should be TVH or Humana (I thought TVH was affiliated with United Healthcare?).

So either the local office (TVH) "coded" too low on the complexity scale and their Insurance company made them raise the "complexity score" (which would seem to indicate shared responsibility for the errors) or ...

The local office coded too high and the Insurance company insisted they lower the "complexity score". (which would mean they weren't getting paid (or billing) enough money, therefore no "fraud"?)

I'm sure I'm missing something in this equation, but I'm not sure what it is.

[Velvet]

Originally Posted by OrangeBlossomBaby

It wasn't just a "computer error." Yes I used that term, yes you're quoting me. I was simplifying it so as to not have to type paragraph upon paragraph of hypotheticals to explain a complicated process that could result in a simple error, that would further result in disastrous outcomes. It was a mis-coding. The computer didn't make a mistake. The input was incorrect. If you've ever worked on a medical billing floor you'd understand how this mistake might be made.

An example: a "yearly checkup" might have several diagnostic codes attached to it. It might be C400, C407, C802, C803, R931 (I'm making those up, they might actually be code for something but I'm pulling them out of my head, not from a coding list). The coder inputs the wrong one. Maybe the routine annual physical is supposed to be C803. But the billing department has been entering it as C802, which might be "specialty yearly checkup for patients with early onset dementia, requiring extra stuff that costs more". Because a yearly checkup - no matter what the code is - doesn't cost the patient anything, the patient will never see a bill for it. But Medicare might see a specialty diagnosis that incurs a surcharge of $270 in addition to the $130 they might be paying for a routine annual physical, which has a different code. They'll pay it, because it's a yearly thing. It won't flag, unless it's noticed that it isn't happening yearly. It also isn't likely to flag when it's a "early onset dementia that costs more" yearly exam, when it's a medical group catering to seniors, since early onset dementia isn't all that uncommon for a group that caters to seniors.

Whoever has been inputting the yearly checkups, has been putting in the wrong ones, over and over again. Medicare's been paying on it, because it really IS a yearly checkup - even though it's the wrong code out of the list of codes for yearly checkups.

It's a mistake. The person entering the code didn't mistype, they miscoded. The Medicare system's accounts payable department never flagged it, because they had no reason to flag it. So it just kept paying out too much.

Until someone in the billing department at TVH brought the incorrect code to their boss's attention.

That's all that happened (though I don't know which code(s) were mis-coded, I was using a hypothetical above). It caused a HUGE financial disaster, but the error itself was simple, and not nefarious.

To take your example of miscoding, say $270 vs $130 for the type of visit. For one year of over billing $90,000,000 they would have had to miscode 642,857 times in order to make such a difference. So each and every person in TV would have to have this “annual checkup” 4 times a year - every year for 4 years - to come up with the magnitude of the error.

Hmmm.

[Aloha]

I currently have Centerwell as my Healthcare provider. I am not pleased by the competence level of some of the office staff. As they take over in the various locations, they need to ensure that a competent staff is in place that will supply adequate support for the Senior patients. Please be vigilant as the transfer process occurs. I suspect there will be serious issues for some.

[golfing eagles]

Originally Posted by BrianL99

If there's $360M in over billing, it seems the hammer needs to come down on someone, but it's not clear from your characterization, whether it should be TVH or Humana (I thought TVH was affiliated with United Healthcare?).

So either the local office (TVH) "coded" too low on the complexity scale and their Insurance company made them raise the "complexity score" (which would seem to indicate shared responsibility for the errors) or ...

The local office coded too high and the Insurance company insisted they lower the "complexity score". (which would mean they weren't getting paid (or billing) enough money, therefore no "fraud"?)

I'm sure I'm missing something in this equation, but I'm not sure what it is.

I'm not sure what is meant by "local office", but I think the people who missed the boat most are those that created this ridiculous system of diagnostic codes and procedural codes that no one really understands and are either intentionally or accidentally vague at best.

This "coding crisis" began back around 1987 with the advent of "DRG's" (Diagnostically Related Groups) to determine hospital reimbursement, as well as LOS (Length of Stay) parameters and outliers. A new category of employees was created, "the coders". Reimbursement became dependent upon how many diagnoses were listed, but get this, also the order in which they were submitted. Billing departments all over the country told physicians to just list every diagnosis a patient had, whether relevant or not to their stay, and "the coders" would put them in the most beneficial for reimbursement order, which was created by the brain children at CMS in the first place.

Over the years, this grew and grew, and created more regulators (nitpickers) as the coding became more complex and more vague. This created another layer of complexity (and employment), the "outside auditors". Every medical practice had a way of auditing their coding. Small practices would generally conduct internal audits by having a colleague review their encounter note and coding. Large practices and hospitals would hire these "outside auditors" to do the same. This was necessary because it was better to find your own problems/mistakes and self-report than to have CMS find it first, penalties were less severe. TVH is a very large practice and has outside auditors.

CPT coding is almost as complex as ICDM-10 coding in some ways. For traditional fee for service billing, the difference between a 99213 and 99214 is about $40, which can be make or break in a small practice with large overhead. But your documentation better fit the code submitted (Note: I said "documentation. Not how much time you devoted to the encounter, not how much judgement and skill was required, just what you wrote in your note. I'm sure many of you have gone to a physician that spent more time typing into his laptop than engaging you, the patient---this government/insurance industry/lawyer concept of "if you didn't write it down it didn't happen" has pervaded the medico-legal industry and to a certain degree paralyzed meaningful patient encounters in favor of "documenting. What you write is now more important than what you did. Sad.)

The difference between 99213 and 99214 requires an "expanded problem focused history" as opposed to a "problem focused history", 2 items from past history, family history or social history as opposed to none, and at least 2 items in 6 categories of the review of systems. There must be at least 6 systems physically examined, as opposed to one, with 2 items from each of those documented. And then you need a "moderate" level of complexity, which is vaguely defined but has a point system for reviewing lab/x rays/procedures/etc. and best of all an ill-defined "complexity of medical decision making". So from the 3 main categories---history, physical, and complexity---2/3 are necessary for a 99214 (established patient) and all three for 99204 (new patient). I hope this gives the layperson and small idea of just what goes into coding just a simple visit for say HTN and elevated cholesterol, and the pitfalls/potential for errors that ensue. Rest assured, CMS is constantly watching for so called "over coding". They periodically require you to submit 25 notes for review and will gleefully penalize even one mistake. And that's just the CPT billing coding; the diagnostic coding is even more complex. So that's traditional Medicare that I am most familiar with, TVH is reimbursed based upon the more complex billing coding structure, which is also vague and subject to interpretation.

Diagnostic coding is defined in the ICDM-10 handbook of a zillion codes---7 digits with 2 digit modifiers for a total of 9. I defy anyone, even a professional coder, to state they understand the whole system. Here's an example of a real code that I saw a while back:
"Struck by bird, goose, flying, in right flank, renal capsule perforated, minimal blood loss, not requiring dialysis". That must come up about once every 100 million years. But I'll give a more realistic example---"acquired platelet dysfunction". Everybody on aspirin technically has that diagnosis---subject to interpretation. This may have been submitted to an outside auditor who said it's fine. Then, maybe, in negotiation for a sale it came up again and wasn't considered fine. So they is no choice but to self report and now the chips are going to fall where they may. But anyone who jumps on the intentional fraud bandwagon has no idea of what they are talking about. None whatsoever.

[Accidental1]

Originally Posted by golfing eagles

I'm not sure what is meant by "local office", but I think the people who missed the boat most are those that created this ridiculous system of diagnostic codes and procedural codes that no one really understands and are either intentionally or accidentally vague at best.

This "coding crisis" began back around 1987 with the advent of "DRG's" (Diagnostically Related Groups) to determine hospital reimbursement, as well as LOS (Length of Stay) parameters and outliers. A new category of employees was created, "the coders". Reimbursement became dependent upon how many diagnoses were listed, but get this, also the order in which they were submitted. Billing departments all over the country told physicians to just list every diagnosis a patient had, whether relevant or not to their stay, and "the coders" would put them in the most beneficial for reimbursement order, which was created by the brain children at CMS in the first place.

Over the years, this grew and grew, and created more regulators (nitpickers) as the coding became more complex and more vague. This created another layer of complexity (and employment), the "outside auditors". Every medical practice had a way of auditing their coding. Small practices would generally conduct internal audits by having a colleague review their encounter note and coding. Large practices and hospitals would hire these "outside auditors" to do the same. This was necessary because it was better to find your own problems/mistakes and self-report than to have CMS find it first, penalties were less severe. TVH is a very large practice and has outside auditors.

CPT coding is almost as complex as ICDM-10 coding in some ways. For traditional fee for service billing, the difference between a 99213 and 99214 is about $40, which can be make or break in a small practice with large overhead. But your documentation better fit the code submitted (Note: I said "documentation. Not how much time you devoted to the encounter, not how much judgement and skill was required, just what you wrote in your note. I'm sure many of you have gone to a physician that spent more time typing into his laptop than engaging you, the patient---this government/insurance industry/lawyer concept of "if you didn't write it down it didn't happen" has pervaded the medico-legal industry and to a certain degree paralyzed meaningful patient encounters in favor of "documenting. What you write is now more important than what you did. Sad.)

The difference between 99213 and 99214 requires an "expanded problem focused history" as opposed to a "problem focused history", 2 items from past history, family history or social history as opposed to none, and at least 2 items in 6 categories of the review of systems. There must be at least 6 systems physically examined, as opposed to one, with 2 items from each of those documented. And then you need a "moderate" level of complexity, which is vaguely defined but has a point system for reviewing lab/x rays/procedures/etc. and best of all an ill-defined "complexity of medical decision making". So from the 3 main categories---history, physical, and complexity---2/3 are necessary for a 99214 (established patient) and all three for 99204 (new patient). I hope this gives the layperson and small idea of just what goes into coding just a simple visit for say HTN and elevated cholesterol, and the pitfalls/potential for errors that ensue. Rest assured, CMS is constantly watching for so called "over coding". They periodically require you to submit 25 notes for review and will gleefully penalize even one mistake. And that's just the CPT billing coding; the diagnostic coding is even more complex. So that's traditional Medicare that I am most familiar with, TVH is reimbursed based upon the more complex billing coding structure, which is also vague and subject to interpretation.

Diagnostic coding is defined in the ICDM-10 handbook of a zillion codes---7 digits with 2 digit modifiers for a total of 9. I defy anyone, even a professional coder, to state they understand the whole system. Here's an example of a real code that I saw a while back:
"Struck by bird, goose, flying, in right flank, renal capsule perforated, minimal blood loss, not requiring dialysis". That must come up about once every 100 million years. But I'll give a more realistic example---"acquired platelet dysfunction". Everybody on aspirin technically has that diagnosis---subject to interpretation. This may have been submitted to an outside auditor who said it's fine. Then, maybe, in negotiation for a sale it came up again and wasn't considered fine. So they is no choice but to self report and now the chips are going to fall where they may. But anyone who jumps on the intentional fraud bandwagon has no idea of what they are talking about. None whatsoever.

Is this complex coding system the same for Advantage and Traditional Medicare patients?

[HiHoSteveO]

Originally Posted by golfing eagles

Investigating and being guilty are 2 different things. And where was it stated that the DOJ was investigating anyway????

YouTube video of DOJ press conference link below posted a few days ago.
https://www.youtube.com/watch?v=dFtO2fL97gY

[RoseyRed]

Yes I see your point. I do wonder how the audit process did not catch the coding issues mentioned much sooner. Where did all the "extra" money go? Why did TVH not look into why there was so much more money coming in those 4 yrs?

Originally Posted by golfing eagles

OK, I'll try to explain what happened (and realize that 99% of previous posts are just speculative BS):

Let's give an example: A patient taking aspirin after previous vascular surgery for say carotid occlusion has easy bruising. It gets coded as "acquired platelet dysfunction", which is exactly what it is. Or is it? Depends on interpretation. So the outside auditors for TVH tell them it is absolutely correct to use that code (Yes, they have continuous outside auditing). Then they get into negotiations with Humana, and Humana says that's wrong, you can't use that code in this instance. So TVH self-reports the discrepancy to CMS and this whole thing begins. There's more to it that I'm not at liberty to discuss, but there was NO INTENT TO DEFRAUD.

[golfing eagles]

Originally Posted by Accidental1

Is this complex coding system the same for Advantage and Traditional Medicare patients?

Yes. They all come from ICDM 10

[Rainger99]

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) includes over 70,000 diagnosis codes and the CPT (Current Procedural Terminology) code set, maintained by the American Medical Association (AMA), contains over 10,000 procedure codes.

It seems complicated. I would think AI could do it faster and more accurately than a team of people.

[golfing eagles]

Originally Posted by RoseyRed

Yes I see your point. I do wonder how the audit process did not catch the coding issues mentioned much sooner. Where did all the "extra" money go? Why did TVH not look into why there was so much more money coming in those 4 yrs?

Because it wasn’t “extra money”. It was just the expected reimbursement from the submitted billing. And (not that I know anything), the external auditors agreed. There was no discrepancy (not that I know anything) until negotiations with Humana uncovered what Humana thought was wrong coding. When this happens, it is best to self report to CMS, and guess which side the federal investigation would fall on??? No need to guess, we all know the answer