Originally Posted by tophcfa (Post 2454154)

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.

Originally Posted by OrangeBlossomBaby (Post 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.

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.

Originally Posted by jimjamuser (Post 2454224)

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.

Originally Posted by OrangeBlossomBaby (Post 2454027)

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 (Post 2454027)

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.

Originally Posted by Rainger99 (Post 2454148)

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 (Post 2454161)

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?

Originally Posted by CoachKandSportsguy (Post 2453958)

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. .

Originally Posted by BrianL99 (Post 2454113)

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?

Originally Posted by gldfin (Post 2454259)

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.