[Altavia]

Originally Posted by golfing eagles

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?

[golfing eagles]

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

[golfing eagles]

Originally Posted by Altavia

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

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.

[CoachKandSportsguy]

Originally Posted by golfing eagles

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

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. . .

[drducat]

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.

[Cdj1040]

Originally Posted by birdawg

What’s your thoughts on Villages Health filing 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.

[M2inOR]

Originally Posted by drducat

Expected Revenue: Approximately $770 million annually for 55,000 Medicare patients, based on an average of $14,000 per beneficiary...

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.

[Marmaduke]

Originally Posted by tophcfa

I am astounded that anyone could possibly believe this was an innocent computer error. I’ve got some swamp land to sell ya that surrounds Alligator Alcatraz if you honestly believe that. Hundreds of millions of dollars were over billed over years, and the $$$ disappeared and isn’t listed as assets in the bankruptcy filling. And then the error was suddenly discovered and self reported, REALLY? Or they knew they were about to get busted and tried to save face and keep from getting thrown in prison by concocting a far fetched story of presumed innocence? If they actual let an innocent computer glitch over bill, and accept 100’s of millions over several years, then they are guilty of gross negligence, incompetence, and lack of any reasonable internal controls. And what happened to all that money, did the computer error miraculously make it disappear? This doesn’t pass even the most lenient of sniff tests.

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.

[Joe C.]

Not worried one bit.

[Velvet]

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.

[OrangeBlossomBaby]

Originally Posted by Velvet

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.

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.

[Eg_cruz]

Originally Posted by birdawg

What’s your thoughts on Villages Health filing chapter 11

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

[Velvet]

Originally Posted by OrangeBlossomBaby

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.

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.

[joshgun]

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.

[tophcfa]

Originally Posted by joshgun

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.