Like any workforce, some are and some are not.

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

8/15/2025 Presentation "Understanding the Bankruptcy of The Villages Health System"
 

8/15/2025 Presentation "Understanding the Bankruptcy of The Villages Health System LLC"

There was a capacity crowd at Lake Miona Rec Center. After the presentation, when polled, 100% of attendees thought it was fraud not mistake!

Because TOTV does not permit links, please go to NextDoor to find the links to the presentation.

So doctors are complicit in putting down diagnosis of things such as 4th stage kidney failure if your blood test shows increase of BUN value which can be off due to dehydration etc etc


Those can be a one off report and means nothing unless it continues...if your chart shows a list of problems that you are not being treated for or have no knowledge of them you could be a victim.

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.

Good thing our justice system doesn't run on polls of people who have just attended a one hour meeting.

ToTV does allow links and some of us do not have NextDoor accounts.l

Bad example. Stage 4 CKD (Chronic Kidney Disease) is defined as a GFR (Glomerular Filtration Rate) of 15-30. An increase in BUN (Blood Urea Nitrogen) does not qualify by a long shot, so if "doctors" were using that diagnosis in that situation, it would be fraud, but I highly doubt that is the case. And I doubt the "poll" mentioned above, since there is NOTHING that 100% of Villagers will ever agree upon.

Exactly!!!

So, what are the chances that will convince "100%" of the attendees at that meeting?

So dehydration also shows low GFR values...either way both are true . Needs to be watched not put down as diagnosed as.....

Do you have any facts to support this?

So dehydration also sho

[QUOTE=OrangeBlossomBaby;2454027]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.
************************************************** ************************************************** ***
If that's the explanation, I think it's bogus that the billing dept is responsible for "record-keeping". That is medical records responsibility and why would the billing department be ready to charge for a discussion between Dr. and patient which included no extra service. Sloppy, sloppy, sloppy or profit, profit, profit IMHO. Is a patient required to walk into their appt and inform the Dr certain subjects are off limit lest the patient be billed for it?

Who was the presenter for this show?

Anyone who spends the usual 2 weeks of training in any medical facility, has a working knowledge of what box to check for whatever treatment they specifically performed.

iPads screen pops up to clarify bloodwork, BP and so forth.

Then charting is briefly read by NP, PA, Physician, who continues with the visit, checks boxes, adds notes, add information discussed. Notes for follow up, change or continue current meds, specific tests, or speciality appointments.
Then sign off. Entire document is printed for patient to walk out the door.

All the procedures are coded, and usually billed by outside companies. I haven’t in house coded billing for over 15 years.

Unless you are living in a town of 1,000 with one doctor, and his wife is the nurse, and biller. Which is rare. Physicians & hospitals went away from onsite billing, sometimes used the dreaded out of US billing.

I have to ask don’t you go over the paperwork? Because if you don’t involve yourself with your medical visits, and the follow-up notes, check you insurance statements, maybe a family member could help. You would then understand what was billed and is it correct.

Dehydration will primarily affect BUN and to a lesser extent creatinine. You can also look at the BUN/cr ratio---- >40 is pre-renal (dehydration), <20 with an elevated creatinine is usually renal in origin