[jimjamuser]

Originally Posted by tophcfa

In summary, the Villages has, and continues to, grow too fast relative to the necessary infrastructure and employment base needed to support the needs of a very large senior citizen population. It’s one thing when growth outpaces service jobs like irrigation repair or restaurant cooks and service providers, but it’s entirely another level of problem when growth outpaces the availability of quality healthcare. This whole unfortunate thing happening with The Villages Health is exposing a very serious problem for an aging population with greater health care needs than the general population.

Great summary. I have been in Florida since 1968 and there has been one consistent thing and that was CONSTANT change. I noticed it particularly in traffic and commuting. It seemed that the width and lanes of the roads NEVER caught up to the amount of traffic that they had to carry. It seems like the same analogy would apply to healthcare. The population growth overwhelms the healthcare systems.

[MplsPete]

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[JMintzer]

Originally Posted by OrangeBlossomBaby

If that's what happened, then yeah doctors would be complicit. But that's not what happened. Doctors don't do billing, they don't input billing codes. I've explained this before...I'll try it again.

Let's say you have a regular annual checkup, and the doctor asks how you've been feeling. You say you're fine, except your bunion's been hurting lately. The doctor says he can give you a referral to a podiatrist if you want, you say thanks, but my bunion pads are still working, it's probably just the humidity lately.

The doctor inputs the code for the annual physical. He inputs the code for the discussion about your bunion (because it's important to know that there's a history of it, in case you do need a referral, he can tell the podiatrist you've had this problem since at least xyz date and are treating it with bunion pads).

He sends the documentation through the system, and now it's the billing department's turn to deal with it.

The billing department puts in the billing code for the annual physical.
They also put a billing code for a podiatry consultation, because record-keeping is important.

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).

But this is the billing code they've been using for years whenever any of the thousands of patients they have discusses a bunion during an annual physical, and up until now, no one's said "hey wait a minute - why is everyone using this code? Surely some patients have different bunion conversations during their annual physicals?"

So that's essentially what happened.

Never, in my 40 years of practice, did any of my billing staff decide what to bill. I made that decision each and every time...

[asianthree]

Originally Posted by jimjamuser

Great summary. I have been in Florida since 1968 and there has been one consistent thing and that was CONSTANT change. I noticed it particularly in traffic and commuting. It seemed that the width and lanes of the roads NEVER caught up to the amount of traffic that they had to carry. It seems like the same analogy would apply to healthcare. The population growth overwhelms the healthcare systems.

Truthfully we have noticed the residents the farther south you go are far younger than northern areas. When one is in 40s 50s early 60s, healthcare issues isn’t top of their list. The older residents moved from the north, so equal numbers.

By the time the southern residents reach 80s and 90s when some may need multiple physicians and visits. The circle of life in the northern areas will have become younger. I see my dentist twice a year, and have a yearly visit with cardiology. Dermatologist said I wasted his time, come back in 3-5 years or if you find something off color.
Never used a primary care so one less waste of an hour.

[BrianL99]

Originally Posted by OrangeBlossomBaby

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).

Originally Posted by OrangeBlossomBaby

The "issue" with this incident of overpayment has to do with billing codes. Not RAF or PMPMs or guaranteed minimum monthly payments to the Health Center. It is specifically a billing code error.

Start there, and work your way back.

I was told today, by someone who used to do this for a living, that your characterization of how it works, is incorrect for Medicare Advantage Plans.

Originally Posted by Rainger99

If a Medicare Advantage (MA) plan spends more on a particular patient than its capitation rate, the plan itself is responsible for covering the excess cost.

That is why UHC's profits fell 19% last year.

Originally Posted by Rainger99

You say that the issue has to do with billing codes - not RAF or PMPMs.

This is from the Villages Health bankruptcy filing. They are claiming that.

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.

They are ones talking about PMPMs and RAF scores. In fact, I never heard of either term before yesterday.

Are you saying that the Villages Health lawyers are mistaken? That it wasn't about PMPMs or RAF scores?

That same person told me today, you are correct in the way Medicare Advantage Plans get paid. It's all about the patient's "score". Artificially "boosting" scores is how the Insurers/providers make more money.

The person I spoke with was convicted of Medicare Fraud and lost his medical license, so I suspect he knows what he's talking about.

[gldfin]

Originally Posted by CoachKandSportsguy

seems like that would be a first, but lets hope so!

The value is in the assets, physical mostly. . the bankruptcy is in the debt portion being bigger than the asset portion. . .

TVH didn't hide anything, they just found a payment loophole and exploited it until they got caught. . The buyers saw an extremely profitable company and was looking to either buy it, get in on the profitability, ie competitive intelligence, or bankrupt it and buy the physical assets as distressed property.

having worked in M&A along time ago, many interested buyers are also looking for competitive intelligence, even after signing an NDA. . for their own interests. .

How can you make a statement that they just found a payment loophole? Illegally billing incorrect billing codes is not a loophole, it is fraud no different than a collision center billing an insurance company for new original OEM parts and installing non OEM or used parts.thay is a general problem with society today, lack of accountability. Who pays for their overrbilling? Everyone who pays employment taxes.

[spinner1001]

Originally Posted by BrianL99

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?

That sums it up pretty concisely.

The public does not have TVH contracts to say how TVH finances actually work and many posts are mostly BS.

I subscribe to a specialized AI platform for deep research. I had it write a report on Medicare Advantage micro economics from CMS to MA plans to MA clinics. The document is long and dense for two reasons. The government's MA program is complicated and, second, for clinics, MA micro economics depend on their particular contracts with MA insurance plans. Contracts differ. If you have seen one contract, you have seen one contract.

Below is a link to the report on Medicare Advantage micro economics from CMS to clinics (providers). Again, it's long and dense. Happy reading. There will be a quiz next Friday.

Dropbox

[CoachKandSportsguy]

Originally Posted by gldfin

How can you make a statement that they just found a payment loophole? Illegally billing incorrect billing codes is not a loophole, it is fraud no different than a collision center billing an insurance company for new original OEM parts and installing non OEM or used parts.thay is a general problem with society today, lack of accountability. Who pays for their overrbilling? Everyone who pays employment taxes.

ok, loophole is a colloquial term, and there are different interpretations.
I am in no way saying their loophole wasn't fraud, i have stated before that their audits were paid for to pass, but i suspect that it's the same up coding which others are using, until they get caught. .

There are always gray areas in accounting, and many keep trying the same scam years apart. If you go back to read some of my posts on the topic, you will see that I in no way find what they did not fraudulent. .

there are always ways to cheat, everyone who takes their profession seriously knows where the line exists. Most choose not to go over the line, some people like to get as close to it as they can, others get close and then without repercussions, keep going farther and end up over the line. Many are over the line until someone decides to actually penalize them. . until then, they feel great knowing that they think they have beaten the system.

I have seen it personally,

[Rainger99]

Originally Posted by spinner1001

That sums it up pretty concisely.

The public does not have TVH contracts to say how TVH finances actually work and many posts are mostly BS.

I subscribe to a specialized AI platform for deep research. I had it write a report on Medicare Advantage micro economics from CMS to MA plans to MA clinics. The document is long and dense for two reasons. The government's MA program is complicated and, second, for clinics, MA micro economics depend on their particular contracts with MA insurance plans. Contracts differ. If you have seen one contract, you have seen one contract.

Below is a link to the report on Medicare Advantage micro economics from CMS to clinics (providers). Again, it's long and dense. Happy reading. There will be a quiz next Friday.

Dropbox

The article is long and dense!

The more I look at this issue, the more confused I get. I started out thinking that Medicare pays Medicare Advantage a certain amount of money each month for each patient.

This is from the Medicare handbook.

When you join a Medicare Advantage Plan, Medicare pays a fixed amount for your
coverage each month to the private company offering your Medicare Advantage Plan.

And this is from another website.

Rather than directly covering care as needed, the federal government pays lump sum Medicare dollars, known as capitated payments, to these private insurers for each patient.

I thought that once Medicare makes the monthly payment to UCH, Medicare is out of the picture and Medicare Advantage is responsible for making any payments to the doctors or clinics.

That is why I can't figure out how Medicare is involved. They made their monthly payment to UHC and UHC had to pay for medical treatment submitted by TVH. If TVH was making mistakes in coding, UHC would be the victim - not Medicare.

However, after reading the TVH bankruptcy filing, it appears that the major issue was that the HCC codes were incorrect and this lead to higher RAF scores which in turn lead to higher payments from Medicare to UHC. But I still can't see how TVH benefited from that. Wouldn't the payment go directly to UHC (or Humana or Blue Cross)?

The goal seems to be to get as much money from Medicare and spend as little money on medical treatment.

There was an article in the NY Times on October 8, 2022, discussing how the MA insurers were being sued for adding additional illnesses to their patients' records. However, it said nothing about how doctors or clinics were benefiting from the HCC codes and RAF scores.

Perhaps there is something in the contracts between TVH and the MA insurers that would explain this. Hopefully, it will come out in the bankruptcy proceeding or the Villages Daily Sun.

[CoachKandSportsguy]

https://www.talkofthevillages.com/fo...76-post10.html

this post might explain how the changes in billing codes from line item to bundled changes the profitability of the physicians office, and if the coding update is missed or not adhered to, past billing practices which were outdated can result in lots of over billing. .

again, the management / auditing oversight was lacking in maintaining up to date coding as designated by CMS. .

I suspect that there will be a few more of these as well as future changes in medical services here in TV as a result of the medicare billing changes to reign increased longevity related medical costs. . sux to have a society who increased life spans, and then have the medical system effectively stop supporting them. . many medical practitioners will be fine with a mix Medicare and private pay balance, to keep the doctors solvent, but most retirees will not be. .

rock meet hard place. .

[BrianL99]

Originally Posted by Rainger99

The goal seems to be to get as much money from Medicare and spend as little money on medical treatment.

There was an article in the NY Times on October 8, 2022, discussing how the MA insurers were being sued for adding additional illnesses to their patients' records. However, it said nothing about how doctors or clinics were benefiting from the HCC codes and RAF scores.

Perhaps there is something in the contracts between TVH and the MA insurers that would explain this. Hopefully, it will come out in the bankruptcy proceeding or the Villages Daily Sun.

This is strictly a guess. I have no 1st hand knowledge, but based on what I'm reading and hearing about this situation, this is my speculation (for whatever that's worth).

The only way that TVH can be responsible, is if they were billing Medicare, directly. Which means that TVH was the "provider" and not the insurance company. It seems like the arrangement between the Insurer & the Provider, is not what many presume it to be. The Insurer may only be responsible for providing management of the subscriber/provider relationship and supplying the over-riding financial backing for the Group Practice.

Sort of like the Insurance company is a "back-stop", that provides high-level oversight and protection from catastrophic losses.

...either that, or TVH is simply paying the Insurance company to use it's name and their business is essentially self-contained?

[ScottFenstermaker]

Meanwhile, the Daily Sun, which (because of its ownership by the Developer) could clarify all this stuff, continues to bury the story.

[BrianL99]

Originally Posted by ScottFenstermaker

Meanwhile, the Daily Sun, which (because of its ownership by the Developer) could clarify all this stuff, continues to bury the story.

"Burying it" would presume they acknowledged it.

I don't know that they've even acknowledged it so far. Then again, I opened the Daily Sun only once since I came to TV and immediately tossed it in the circular file.

[OrangeBlossomBaby]

Originally Posted by JMintzer

Never, in my 40 years of practice, did any of my billing staff decide what to bill. I made that decision each and every time...

You weren't an employee of a large health care organization. Doctors at TVH don't have their own billing staff. They are EMPLOYEES, this isn't a private practice and they're not contractors or sub-contractors or doctors who lease space in someone else's medical center.

The doctors input what they did and the diagnostic code that corresponds with it. The billing department matches the diagnostic code with a billing code (or multiple billing codes) and inputs that. If there's more than one billing code for a diagnostic code, or series of diagnostic codes, then the billing department decides which billing code is applied. The doctor has nothing to do with it at that point.

[Rainger99]

Originally Posted by BrianL99

This is strictly a guess. I have no 1st hand knowledge, but based on what I'm reading and hearing about this situation, this is my speculation (for whatever that's worth).

The only way that TVH can be responsible, is if they were billing Medicare, directly. Which means that TVH was the "provider" and not the insurance company. It seems like the arrangement between the Insurer & the Provider, is not what many presume it to be. The Insurer may only be responsible for providing management of the subscriber/provider relationship and supplying the over-riding financial backing for the Group Practice.

Sort of like the Insurance company is a "back-stop", that provides high-level oversight and protection from catastrophic losses.

...either that, or TVH is simply paying the Insurance company to use it's name and their business is essentially self-contained?

I am surprised that no one - the Villages, the government, the Insurance Companies, the attorneys or anyone else has issued any kind of statement explaining how the over-billing happened.

Or that details have not leaked.