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.

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.

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.

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?

DOJ Investigation results. - Healthcare Fraud Takedown 2025
 

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

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?

Yes. They all come from ICDM 10

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.

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

What's the odds Humana would find similar discrepancies with any other practice?

All I can say is that if jumping to conclusions were an Olympic sport, this thread would hold the world record

Humana, a random outside auditor, or CMS can find similar discrepancies with EVERY practice. The reason is that the definitions of many diagnoses are extremely vague. And if you ask CMS what they want you to code in a given circumstance or how to do it, they WILL NOT GIVE YOU AN ANSWER. But don't ever actually ask them, because they will flag you for increased surveillance.

All makes sense, until you realize that there are different levels of auditors. Yes, how do I know? because an excellent corporate accounting friend was witness to all the TYCO accounting and GE accounting which was illegal, TYCO CFO went to prison, GE was finally caught, and the auditors signed off. Same friend also worked at a private accounting firm where the owners would forge documents if that is what the customer wanted. I personally worked with some E&Y auditors, who I had to report to my superiors as breaking the law., putting the company at risk. Auditors go mad at me. .

Enron auditors? where were they? Arthrr Anderson, where are they now?

All auditors are not the same, especially as the firms get smaller and are private. . .

Expected Revenue: Approximately $770 million annually for 55,000 Medicare patients, based on an average of $14,000 per beneficiary.Expected Profit (Loss): Likely a loss of $157.7 million annually, assuming Medicare reimburses 83% of costs. In an optimistic scenario with cost optimization, a small positive margin (e.g., $38.5 million) is possible but unlikely without commercial payer revenue or special programs like 340B. Tuff to make any money without some fancy coding or diagnosis. Inconclusive risk assessment is at play here.

Villages Health Ins chapter 11
 

Glad we opted for United Health Care Medicare Advantage thru AARP.
It covers nationwide and I have used it up north with no problems. Many providers to choose from. If you travel at all stick to insurance with out of area coverage. I managed a medical office so right away after checking it out, we avoided Villages Health in spite of their lovely buildings and one stop medical care ideology. Better to shop providers, check their training, and choose your own wherever you happen to be.

The above quote is worth paying attention to.

This is the amount the US government pays each year automatically for each Medicare Advantage patient member, over and above what is being billed.

This gives The Villages Health and other primary healthcare providers a fixed amount to support the operation. Before coming to the Villages, we had a Medicare Advantage plan with Kaiser Permanente in Oregon. We had Kaiser HMO for all our working years before retiring at 65 and enrolling in Medicare.

We liked the HMO very much, so taking the Medicare Advantage when we retired was an easy choice for us. Our experience with UHC and Medicare Advantage with TVH has been excellent, too.

I hope this gets resolved quickly. And I hope the uninformed speculation disappears when replaced by facts. I want TVH to continue to provide the excellent Healthcare my wife and I have received over the past 5 years.

I Concur with You 100%, and I'm a very logical person who would give any company the benefit of the doubt.
This deserves deep Federal Investigation, and nothing less, I'm sorry to say.

Not worried one bit.

In mathematics, a true mistake goes both ways. One would err as often towards less as towards more of the correct figure. My internet provider consistently “errs” in their favor only, which means they are not erring at all. The bill is never lower than what it should be, only higher. So no it is not a “mistake”. Adding any degree of complexity, would not change this probability.

Hmmm indeed! So - maybe - just maybe - you should accept that I said this was all hypothetical, an example of what kind of error might be made, and not focus on the dollar amount because the dollar amount clearly doesn't apply in the situation.

Consider the POINT:

A set of codes can apply to similar procedures. A billing error isn't a dollar amount. It's a coded diagnoses, which has a base cost attached to it.

WHATEVER THAT COST MIGHT BE....

Someone put in the wrong code, which came with a higher base cost than the correct code.

The result was an overpayment with no red flags, because the procedure attached to the code was correct, therefore not causing any red flags to go up.

I know one of the doctors who started so I am not surprised
Bad management and greed

In order to bill $90,000,000 over CONSISTENTLY over years, and never under, makes it unlikely to be an error, more like accepted practice. At least it would be in most circumstances.

In Advantage plans the plan is paid a flat fee on a per person adjusted for those with more significant problems. If TVH requested and was paid $90 million a year than Medicare the taxpayers are stuck with loss. One thing to keep in mind is how can TVH continue under Centerwell with $90 million less each year? Expect premium increases.

The obvious answer is by buying TVH assets at a fire sale valuation and either not taking on their liabilities or by taking on significantly restructured liabilities. With significantly lower overhead costs, they have a reasonable chance of turning a profit using coding that generates less revenue.

The Villages Health is not on that list of defendants. I just checked the .gov website. TVH is not being investigated by the DOJ, at least not in conjunction with this "Takedown" project.

Too soon to tell. Self-reporting is a CYA in case there are real legal problems. We had a RAC audit by Medicare that challenged nearly every case we use IMRT treatments (even when the treatment was considered Standard of Care!), and they wanted to claw back all the money. We appealed and had the documentation to support our work because our Department Director was OCD about having documentation complete to justify every charge. We won ALL BUT ONE CASE, and the one we lost we should have won but Medicare argued we should have used a cheaper therapy that would have caused more side effects for the patient because the outcome would be the same. Until we know more about the predominant charges, it's hard to determine REAL errors or fraud.

The error, if you were to figure this out logically, would be - that the accepted practice was incorrect OR *became* incorrect with the new potential buyer's system of "doing things."

See golfing eagles's post for a detailed explanation on that.

In summary:

"Our practice has been coding "widget fixing and whatsit-testing" as W401 for the past 15 years. It bills out at $5000 per incident. Medicare only allows $3000 per incident, pays $2980 per incident, and the patient pays $20."

Then Humana shows up and says "hey maybe we'll buy you." TVH says "let's self-audit to see what this bad boy is worth."

And they discover "omg Humana uses code W407 and W294 for these two things, separately. And combined those codes can only be billed at $2000. Medicare will only allow $1500, and will only pay $1480, with a $20 co-pay from the patient."

Considering that most patients have to have widget fixing and whatsit-testing at least once per year, and they have 55,000 patients, and some of those patients have to have these tests twice and even three times a year - there's gonna be a WHOPPING discrepancy.

The patient never sees any change - they're still on the hook for a $20 co-pay, no matter which way it's coded.

So at the end of the day, medical providers are being punished for not denying medical services an auditor on third review felt were unnecessary?

How did you conclude that, exactly? I’d just like to follow your thinking. Are you saying that medical practitioners were advising care to patients that was not covered but they were billing for it anyways? I am not sure I understand you.

The health care system really could benefit from universal care at a reasonable level, so that one would not have to “game the system” to provide decent care (in my opinion).

The government calls it fraud--Fraud was discovered....

Just the opposite, Humana auditors are retrospectively over ruling the original medical code, that was also approved by two lower level auditors?

How many complaints have we heard about needed medical care being denied by insurance providers?

As a firm believer in statistics, you’re speaking my language. Statistics, using large random sample sizes don’t lie. If all codes used by TVH were analyzed for under billing, accurate billing, and over billing, a bell shaped curve would indicate random billing errors and wouldn’t suggest fraud. If the curve was highly skewed toward overbilling, randomness (in this case intentional coding toward over billing) would most definitely come into question. I’m not saying this is what happened, but if I was investigating a health care provider for possible fraud, I would have some sharp young math wiz, with an advanced degree in data sciences, crunching these numbers. If I was running the health care providers business, I would have a similar math wiz write a multi factored optimization algorithm that figured out how to reverse engineer the coding system for billing, so that codes could always be used that maximize revenue while staying within constraints that would trigger regulators (CMS) up coding flags. Thinking about it, Golfing Eagles said the CMS keeps everything about the system extremely vague and subject to interpretation, most likely on purpose to make it extremely difficult to identify the constraints triggering flags, making it almost impossible to write a coding optimization model. I’m glad I wasn’t in that line of business.

Unfortunately, sometimes the need exceeds what can be paid for. Just a quick story; when I first started teaching I noticed the janitor worked with an oxygen tank. I asked him about it and he said, he can afford the oxygen only for another several months after which he will most likely die. I thought he was kidding. Nine months later he was gone. I asked around and they told me, he had passed away.

Confused
 

I am missing something. With the Medicare Advantage Plan, I thought that Medicare paid a fixed amount to your insurance company to cover your medical expenses and that the insurance company and not Medicare was billed for your care. If that is the case, how did Medicare overpay The Villages Health?

100% correct, and surprisingly close to what actually happened

And just where did the government state it was fraud???

No, it wasn't. The DoJ isn't investigating The Villages Health for fraud. There has been no fraud found with regards to this coding error at The Villages Health.

No fraud was discovered. It was a coding error. The Villages Health DISCOVERED it, and reported it to the government department in charge of dealing with government-paid health insurance payments (in this case, Medicare Advantage, primarily), and that entity ACCEPTED The Villages Health's assessment that they were overpaid due to a coding error.

That is all. That's all that happened. You might want to blame the prior administration for allowing TVH to commit this massive fraud. You might want to vilify TVH for committing this massive fraud. You have permission to want these things. But no amount of wishing will make it actually true.

Actually, just the original code and one "lower level" auditing company.

Contrary to popular belief, I am possessed of critical thinking skills. While not having much "expertise" in a variety of subjects, I am an expert in "looking stuff up." You should try reading the ENTIRE Connecticut General Statutes some time. All thirteen volumes (not including the 3 index volumes). If you went to a Connecticut public library and checked the physical bookshelf, you'd discover it's well over 8,000 pages (not including the 3 volumes of indexes). It's an eye-opener. I only read it because I wanted to help a friend who needed legal advice about her boyfriend adopting her son, whose biological father was a homeless drug addict with no known location or contact information. But it was interesting enough that I ended up reading the whole damned thing.

Mom always said - education for its own sake is priceless.