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.