Here is an article from a law firm discussing burden of proof in bankruptcy actions.

Asserting a Proof of Claim in Bankruptcy

Hopefully we have some bankruptcy lawyers on TOTV that can elaborate on the issue.

I still don’t understand why Medicare is the main creditor instead of UHC, Humana, or Florida Blue.

Thanks for the link. To try to answer your question as best I can, reading through the bankruptcy court filing by Florida Blue, on page 3 section 5, it states that typically 90% of overpayments are passed along from Florida Blue to the debtor (TVH).

I've asked the question a couple of times.

The only scenario that seems to make sense, is TVH is some sort of "Licensee" of the various insurance companies and they bill Medicare directly, as the Provider.

As you point out, if UHC, Humana or FB was the "Provider", they would be the one that owe the money.

It’s confusing, see the above post (#137). TVH is the provider or medical services and determines the diagnostic codes that are submitted to CMS. Based on the diagnostic codes, CMS makes the payments to the patients Medicare Advantage insurer. According to Florida Blue, typically 90% of those payments are passed through to the provider, which is TVH in this case. So in this case, the biggest creditor, which is Medicare (via CMS), is due back 90% of any overpayments collected by the debtor/provider (TVH). I guess theoretically, the MA insures (United Health Care, Florida Blue, Humana) are on the hook to pay back the other 10% of the overpayments to CMS that were not passed through to TVH, but as far as I can tell that isn’t part of the bankruptcy case in question.

This is my question.

Every Medicare patient has an individual health score called RAF. An RAF of 1 is average and anything above 1 means that your health is below average and anything that is below 1 means your health is better than average. Medicare has a fixed rate per county to determine the value of 1. Assume that it is $1,000 for Sumter County.

In that case, Medicare would pay advantage plans $1,000 for every patient rated 1 and $1,500 for every patient rated 1.5. I think Medicare determines the RAF score based on the doctor’s evaluation of your health. I don’t think advantage plans have anything to do with RAF scores but I could be wrong on that point.

Since the money goes directly to the advantage plans, I don’t understand how TVH benefits from having patients being rated with high RAF scores. If a person that should be a 1 is rated 1.5, I would think that the patient would not need $1,500 a month in treatment but would need only $1,000. Does that extra $500 go to TVH or remain with the advantage insurer?

Florida Blue mentioned something about 90% of the overpayments going to TVH. How does that happen?

I obviously don’t understand how it works but someone should have a basic understanding of Medicare reimburse procedures.