[Rainger99]

Currently, the Villages Health takes Advantage plans from UnitedHealthcare, Humana, and Florida Blue.

Has there been any statement from UHC or Florida Blue that they will stay with TVH - especially if Humana owns it?

[Altavia]

Originally Posted by Rainger99

Do you have any facts to support this?

As someone who spent 45 years around hospitals and medical system diagnostics, Asianthree, OBB and GE are speaking reality.

[BrianL99]

Originally Posted by Rainger99

This is the best explanation that I have seen for the coding discrepancies. It is from the TVH's bankruptcy filing.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that Centers for Medicare and Medicaid Services (CMS) pays MA plans depend on a number of risk adjustments factors (“RAF Scores”) that are meant to reflect the illness level of patients. Generally speaking, MA plans receive higher PMPM payments for patients who have higher RAF Scores and are anticipated to have higher medical expenses than patients with lower RAF Scores. Hierarchical Condition Categories (“HCC”) codes are a significant input in the calculation of RAF Scores. Through its contracts with MA plans, TVH generally receives larger payments for beneficiaries with higher RAF Scores.

I thought that the insurance companies receive larger payments - not the TVH.

Article on Risk Adjustment Factor (RAF) score fraud.

Understanding Risk Adjustment Factor (RAF) Score Fraud and How to Get a Reward for Reporting It - Daniel J. Ocasio Whistleblower Law Group

Originally Posted by OrangeBlossomBaby

You only pay your co-pay, which is probably 0 since it was all part of your physical exam.
But the insurance company sees the code for the podiatry consultation, and sends your doctor's office a check for $197 instead of $143, because an annual physical plus podiatry consultation pays out $197.

But here's the thing - there are 7 different billing codes that COULD be input, for a brief moment's worth of discussion with a doctor during an annual physical about your bunion. The one your doctor's billing department chose was the wrong one. The one they were supposed to choose should have resulted in a $146 payment, not a $197 payment (and not the bare-bones $143 payment either).

I thought with Medicare Advantage Plans, the Payments from Medicare were essentially as Rainger laid out. A "monthly payment per patient", based on their level of need.

I thought traditional Medicare (NON Advantage Plans) made payments per what OBB laid out.

It can't be both ways. Either they pay a "lump sum" per month, based on a Patient's level of complication or they pay individually, for specific procedures.

It sounds to me, like two separate and distinct Medicare fraud/over-billing/mis-coding. In one instance, the patient's general health/complications are inflated for a larger monthly payment.

In the other instance, the patient's individual procedures are miscoded or exaggerated.

Which is it?

[Rainger99]

Originally Posted by Altavia

As someone who spent 45 years around hospitals and medical system diagnostics, Asianthree, OBB and GE are speaking reality.

Those aren’t facts.

Post a link to the bankruptcy filings that support their statements.

[spinner1001]

Originally Posted by BrianL99

I thought with Medicare Advantage Plans, the Payments from Medicare were essentially as Rainger laid out. A "monthly payment per patient", based on their level of need.

No. CMS also pays MA plans incentive bonuses when plans surpass certain patient health benchmarks.

Medicare Advantage Quality Bonus Payments Will Total at Least $12.7 Billion in 2025 | KFF

Bonus payments to a MA plan can be millions of dollars.

CMS pays a MA plan periodic risk-based rates plus potentially bonuses. Then the plan pays the MA clinic (provider) based on whatever contract terms the plan and clinic negotiate.

[BrianL99]

Originally Posted by BrianL99

I thought with Medicare Advantage Plans, the Payments from Medicare were essentially as Rainger laid out. A "monthly payment per patient", based on their level of need.

I thought traditional Medicare (NON Advantage Plans) made payments per what OBB laid out.

Which is it?

Originally Posted by spinner1001

No. CMS also pays MA plans incentive bonuses when plans surpass certain patient health benchmarks.

Medicare Advantage Quality Bonus Payments Will Total at Least $12.7 Billion in 2025 | KFF

Bonus payments to a MA plan can be millions of dollars.

CMS pays a MA plan periodic risk-based rates plus potentially bonuses. Then the plan pays the MA clinic (provider) based on whatever contract terms the plan and clinic negotiate.

That wasn't the question.

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

I doubt it can be both ways. OBB's scenario of the "bunion story" presumes Medicare is invoiced for and pays, for each individual visit and/or procedure. I don't think that's the case with Medicare Advantage Plans. I think Medicare simply pays a "lump sum" per patient, depending on the patient's overall health condition. ("Bonuses" are irrelevant to the question).

[Zenmama18]

Originally Posted by tophcfa

I’m sure it would have been interesting to be a fly on the wall at the August 6th creditors meeting. Hopefully the bankruptcy court is prioritizing the best interest of TVH patients throughout this process?

Probably not, more likely to prioritize the best interests of the creditors.

[rsmurano]

For me, The biggest issue with TVH is that they only take Medicare advantage plans which I think is a huge mistake.
Also, there can never be a monopoly in the health care system in TV. There are more drs outside of the TVH system so people have many choices on who to see. Also, no dr is dedicated to 1 company. There is so much turnover in drs around here, no company could state they will have this specialist tomorrow. My wife, before she was on Medicare, was going to drs in the TVH system that disappeared before her next 6 month visit so she was constantly having to re-establish with a new dr. Now being on a Medicare supplement plan g plan, she has seen the same dr at other facilities.

[golfing eagles]

Originally Posted by rsmurano

For me, The biggest issue with TVH is that they only take Medicare advantage plans which I think is a huge mistake.
Also, there can never be a monopoly in the health care system in TV. There are more drs outside of the TVH system so people have many choices on who to see. Also, no dr is dedicated to 1 company. There is so much turnover in drs around here, no company could state they will have this specialist tomorrow. My wife, before she was on Medicare, was going to drs in the TVH system that disappeared before her next 6 month visit so she was constantly having to re-establish with a new dr. Now being on a Medicare supplement plan g plan, she has seen the same dr at other facilities.

I think you would find the high turnover rate is due to the fact that there are just as many, if not more, physicians at TVH that are near the end of their career than those at the beginning of theirs. Young doctors tend to want to be near urban areas and suburbs with children for playmates for theirs. There is little attraction for a young family in a 55+ retirement community. Plus, the salaries are higher elsewhere.

[maggie1]

Originally Posted by CoachKandSportsguy

legal tactic, but potentially true, given the perceived omnipotence of the TV corporate empire abilities to control the local and state legal and political system with crony mafiaism. .

I wouldn't discount it, given my experiences with corporate america, and the quest for power/control and money. .

a monopoly is the first place winning trophy of any and every capitalistic venture. .

I guess I needed to have chosen a different profession to understand all of this, but I didn't. What I do understand (I think) is that the Village Health System is on the hook for $300,000,000 in over-billing to United Health. So, will someone please answer me this:

1. Where did that money end up, and who profited from it?

2. With that amount of fraud involved, who was responsible for it, and why haven't criminal charges been filed?

3. Will United Health still be our primary insurance provider, or will they bow out?

If somebody doesn't get some time (prison) out of this, then my faith in the justice system will have eroded even further.

[BlueStarAirlines]

Originally Posted by Snowbirdtobe

How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?

UnitedHealth has their own Medicare billing issues with the Government that dwarfs the Villages Health issue.

RemovePaywall | Free online paywall remover

[spinner1001]

Originally Posted by BrianL99

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

Pay who? The MA plan or clinic?

Regardless, neither described by Rainger and OBB is necessarily true for MA. If the MA financial model were simple, there would be less disagreement and confusion.

[Biskopski]

It wasn't losses. They overbilled Medicare and got caught from the government DOGE audit.

[BrianL99]

Originally Posted by BrianL99

That wasn't the question.

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

.

Originally Posted by spinner1001

Pay who? The MA plan or clinic?

Regardless, neither described by Rainger and OBB is necessarily true for MA. If the MA financial model were simple, there would be less disagreement and confusion.

Based on the fact that Medicare is saying TVH "over-billed" them, that must mean that Medicare pays TVH directly (which surprises me). It sounds like the Insurance carrier is just a "middle man", providing management of the patient/doctor relationship.

With 100's of posts on the subject, it seems someone must actually know the formula for how TVH gets it's revenue and from whom. Again, Rainger & OBB's characterizations of the payment structure/arrangement are diametrically opposed ... two separate and distinct arrangements.

Does Medicare pay TVH a specific amount per patient, regardless of what or how many procedures they have (adjusted only for bonuses and/or "complexity" level of their conditions) ....

Or ... does Medicare pay TVH per visit and/or per procedure, as OBB claimed in the bunion story.

& how does the insurance company get paid, if they're not billing Medicare directly?

Call me crazy, but if no one understands how billing and payments actually work, how does anyone have an opinion on who's getting pork'd and how?

[golfing eagles]

Originally Posted by Biskopski

It wasn't losses. They overbilled Medicare and got caught from the government DOGE audit.

That statement couldn't be more wrong! They MAY HAVE "overbilled", depending on which interpretation of ICDM-10 diagnostic criteria is applied. This was discovered during negotiations for being acquired by Humana, and self-reported to CMS BEFORE DOGE EVEN EXISTED, BEFORE THE ELECTION AS WELL.