[Rainger99]

I am listening to the radio and I just heard an ad talking about the No UPCODE Act. Never heard of it until five minutes ago. It talks about risk adjustments and coding.

[blueash]

I will do my best to explain, my understanding, of how this works. Medicare (CMS) gives private carriers (UHC, Humana etc) an opportunity to cover patients who qualify for Medicare. Those carriers are paid a fixed amount per covered life to cover all costs, physicians, hospital, pharmacy, lab, etc.

The only adjustment comes if it turns out that the patients who enroll are sicker than the average Medicare aged patient. If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.

So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.

Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works. In the case of fee for service then the only way to increase payment is to bill for services at a higher level or complexity. I can tell you from my own EOBs that I see no evidence of that being the case. A routine exam is being billed with the correct codes, and illness visits are also being correctly billed as to complexity. I have seen no charges for services not done.

Lastly, entirely IMO, I do not believe any of this was fraud. Rather it is a quirk in the system where the doctor wants everything in the chart for completeness but that completeness makes the patient look sicker as most offices don't bother computer entering everything.

What is needed is a way to enter a concern, but to be able to note that it is not requiring management. There are so many of these that every patient has. A patch of dry skin, occasional headaches that have been for years, mild spring allergies, intermittent constipation. These kinds of things are true, real, and should be noted. But if there is not ongoing management, just living with it, the entry in the record becomes a problem as CMS cannot differentiate actively managed vs not managed.

[CoachKandSportsguy]

Originally Posted by blueash

I will do my best to explain, my understanding, of how this works. Medicare (CMS) gives private carriers (UHC, Humana etc) an opportunity to cover patients who qualify for Medicare. Those carriers are paid a fixed amount per covered life to cover all costs, physicians, hospital, pharmacy, lab, etc.

The only adjustment comes if it turns out that the patients who enroll are sicker than the average Medicare aged patient. If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.

So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.

Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works. In the case of fee for service then the only way to increase payment is to bill for services at a higher level or complexity. I can tell you from my own EOBs that I see no evidence of that being the case. A routine exam is being billed with the correct codes, and illness visits are also being correctly billed as to complexity. I have seen no charges for services not done.

Lastly, entirely IMO, I do not believe any of this was fraud. Rather it is a quirk in the system where the doctor wants everything in the chart for completeness but that completeness makes the patient look sicker as most offices don't bother computer entering everything.

What is needed is a way to enter a concern, but to be able to note that it is not requiring management. There are so many of these that every patient has. A patch of dry skin, occasional headaches that have been for years, mild spring allergies, intermittent constipation. These kinds of things are true, real, and should be noted. But if there is not ongoing management, just living with it, the entry in the record becomes a problem as CMS cannot differentiate actively managed vs not managed.

Fact check: TRUE

However, one can go into their electronic medical records and make adjustments, if they are using EPIC.

When I questioned the doctor about the forever list, he said its there for reference of past medical history issues. . "OK", until you get to Medicare.

However, I am not yet on Medicare, and will convert at the end of this year. . when I have to then have a "Medicare" physical. .

One last point about physician services codes and billing codes:
In large systems, such as EPIC in large hospital systems, there is automation for many of the mundane and commonly used service codes to billing codes.

However, there is constant reviews and auditing methods to insure proper compliance. In physician only medical offices, which may be using small system electronic medical records, the process may be more manual than big hospital systems. . BUT they have a choice of partnering with a major hospital system and using their system as a separate instance. . .

My eye doctors' office uses the Mass general or brighams womens EPIC system, and their hospital payment system. . and am having a billing issue with them right now.

but we learn alot here on TOTV, with all the previous work experiences who have actual knowledge of the issue du jour

[golfing eagles]

Originally Posted by CoachKandSportsguy

Fact check: TRUE

However, one can go into their electronic medical records and make adjustments, if they are using EPIC.

When I questioned the doctor about the forever list, he said its there for reference of past medical history issues. . "OK", until you get to Medicare.

However, I am not yet on Medicare, and will convert at the end of this year. . when I have to then have a "Medicare" physical. .

One last point about physician services codes and billing codes:
In large systems, such as EPIC in large hospital systems, there is automation for many of the mundane and commonly used service codes to billing codes.

However, there is constant reviews and auditing methods to insure proper compliance. In physician only medical offices, which may be using small system electronic medical records, the process may be more manual than big hospital systems. . BUT they have a choice of partnering with a major hospital system and using their system as a separate instance. . .

My eye doctors' office uses the Mass general or brighams womens EPIC system, and their hospital payment system. . and am having a billing issue with them right now.

but we learn alot here on TOTV, with all the previous work experiences who have actual knowledge of the issue du jour

TVH does not use EPIC. I'm pretty sure their EMR comes from a minor league player.

[Rainger99]

Originally Posted by blueash

If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.

So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.

Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works.

I thought that the extra money that goes to the insurance company stays with the insurance company but it is assumed that a person with a high RAF score will have more treatment than a person with a low RAF score. If a person has severe health problems, I expect that they see the doctor more frequently than the average person and that the treatment is more complicated.

I don't see how the provider ends up making extra because their monthly payment is increased for each patient in the plan. If TVH were diagnosing the patient to be in worse health than they were, UHC gets more money per patient, but I don't see how TVH benefits because the patient would not be getting the extra treatment. Unless the codes pay more depending on the RAF score?

For example, if a person in good health sees a doctor for a physical and the doctor gets $100, does the doctor get $150 for giving a physical to a person that is "supposed" to be in poor health?

Does anyone know if TVH gets captivated payments per patient?

For example, does TVH get $500 a month for a healthy person and $1000 a month for a sick person? I thought the monthly payments go to UHC - not to TVH - and UHC does its best to limit the amount of treatment that TVH gives its patients because the money that doesn't go to TVH stays with UHC.

The whole process seems to be a lot more complicated than it should be!

[golfing eagles]

Originally Posted by Rainger99

The whole process seems to be a lot more complicated than it should be!

Out of hundreds of posts on this topic, most of them "uninformed" at best, that one is 100% true.

[Topspinmo]

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. .

This all my opinion from pass dealing and observations?

IMO UHC scruples practice has been investigated in pass and made sweet deal with VHC. Which also MY OPINION was bad deal based on past investigations. My question? VHC exclusively UHC insurance which billing codes I would think sent to UHC which should have raised flags when billing? But, when feds paid with no alarm bells going off everything seems good right?

IMO Now somebody ratted them out (because maybe they wasn’t getting enough action?) and now all sudden after years of raking in millions it’s now problem. Now they trying to bail with pocket change and sell out the headache they manufactured.

What I don’t understand why business would limit it customer base only allowing one insurance provider? I think we know why? ACA should have fixed insurance monopoly, but guess they had to read it to find out what was actually in it before they passed it?

This all my opinion cause don’t have clue or little clue what practice’s actually do when comes to record keeping and billing, cause if I want MY information in pass I have to pay for it while everybody else gets it for free. Besides, who questions bills unless you have to pay for it?

It also well know fact IMO that health care companies rack up tests, proscribe pills, and procedures to run up bill to stay in business or extra profit. Even dental industry does it with X-rays and the money maker deep cleaning. How do I know this? I been to 4 dentist in 10 years here in Florida. 3 out 4 demanded deep cleaning and X-rays when I just had both that less than 6 months form other dentist I ran from.

[Topspinmo]

Originally Posted by golfing eagles

Out of hundreds of posts on this topic, most of them "uninformed" at best, that one is 100% true.

Isn’t that why have forums? To post B—S we know nothing about to find out? otherwise why have forums if take questions out?

[drducat]

Your RAF score is calculated by your insurance provider. They use what your doctor puts down during your first yearly visit...it resets every year in Jan.

[Rainger99]

Originally Posted by drducat

Your RAF score is calculated by your insurance provider. They use what your doctor puts down during your first yearly visit...it resets every year in Jan.

From my research, Medicare calculates it - not the insurance company.

I think Medicare calculates it on information from your health provider - and not from your insurance company.

[drducat]

Medicare Advantage organizations calculate the RAF score for their enrollees.
This is based on data from patient encounters, including diagnoses (ICD-10 codes) and demographic information.
The data is submitted to CMS (Centers for Medicare & Medicaid Services) for processing.

[Rainger99]

I am attaching the new ICD-10-CM Official Guidelines for Coding and Reporting that go into effect on October 1, 2025. It is 120 pages!

I am glad that I didn't go to medical school!

https://www.cms.gov/files/document/f...guidelines.pdf

[ScottFenstermaker]

Medicare lawyers are soliciting in The Villages. I wonder if TVHS doctors are starting to lawyer up. Click here: (The link works.)

federal-lawyer.com | 520: Web server is returning an unknown error

[golfing eagles]

Originally Posted by Rainger99

I am attaching the new ICD-10-CM Official Guidelines for Coding and Reporting that go into effect on October 1, 2025. It is 120 pages!

I am glad that I didn't go to medical school!

https://www.cms.gov/files/document/f...guidelines.pdf

Only 120 pages? The last manual I handled was about 3-4 inches thick. Must be the abridged version

[Nucky]

Originally Posted by golfing eagles

Out of hundreds of posts on this topic, most of them "uninformed" at best, that one is 100% true.

Hello, my Friend. I've checked in several times on this particular thread, started reading through, and got discouraged, so I clicked off. Is there any possibility for old times' sake that you could wrap up the future status of my beloved healthcare, and is it possible that it will stay as it is? Hope you are doing well.

The rumors of my recent demise are incorrect. We sure did have a whole lot of fun on here in the old days. Did you ever collect your LOBSTER?