[Dgodin]

Why buy in? 55,000 patients.$$$

[Bill14564]

Originally Posted by BrianL99

Based on the fact that Medicare is saying TVH "over-billed" them, that must mean that Medicare pays TVH directly (which surprises me). It sounds like the Insurance carrier is just a "middle man", providing management of the patient/doctor relationship.

With 100's of posts on the subject, it seems someone must actually know the formula for how TVH gets it's revenue and from whom. Again, Rainger & OBB's characterizations of the payment structure/arrangement are diametrically opposed ... two separate and distinct arrangements.

Does Medicare pay TVH a specific amount per patient, regardless of what or how many procedures they have (adjusted only for bonuses and/or "complexity" level of their conditions) ....

Or ... does Medicare pay TVH per visit and/or per procedure, as OBB claimed in the bunion story.

& how does the insurance company get paid, if they're not billing Medicare directly?

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?

From some very quick reading, here is one possibility:
- A Medicare Advantage (MA) plan receives a monthly amount ($1,000?) per patient regardless of any treatment
- The monthly amount is intended to be more than enough to cover costs which allows the MA plan to off additional services
- The provider sees patients and bills the MA plan for services provided
- If the services provided indicate the patient is sicker than average then the MA plan can bill Medicare extra for that patient
- The additional money paid by Medicare is passed through MA to the provider

- TVH may interact only with the MA plan
- TVH requests reimbursement through coding
- If the coding is within a "normal" range of services, the MA plan reimburses TVH from the monthly amount it receives for that patient
- If the coding is above normal (sicker patient) then MA requests additional funding from Medicare
- The additional funding is passed to the TVH

If it is later found that the "above-normal" coding was inaccurate then Medicare may choose to demand reimbursement. Since the coding was done by TVH and the additional funds were given to TVH it is logical that Medicare would approach TVH for any reimbursement.

Since TVH doesn't have $360M just sitting around to be used for reimbursement, it anticipates a serious problem and has filed for bankruptcy protection.

The above is certainly missing some details and nuances but it seems to be consistent with the description of the flow of funds with Advantage plans and what has been reported in various articles.

[OrangeBlossomBaby]

Originally Posted by BrianL99

That wasn't the question.

The question is, does Medicare for Advantage plans pay a "lump sum per patient" (as Rainger said) or do they pay per individual visit/procedure (as OBB said)?

I doubt it can be both ways. OBB's scenario of the "bunion story" presumes Medicare is invoiced for and pays, for each individual visit and/or procedure. I don't think that's the case with Medicare Advantage Plans. I think Medicare simply pays a "lump sum" per patient, depending on the patient's overall health condition. ("Bonuses" are irrelevant to the question).

If you want the answer to that, first consider the common sense answer, using a common hypothetical.

MA pays X dollars for patient John. Every month. No more, no less. And then John is found to have a brain tumor that is treatable with chemo, targeted radiation, months of physical and speech therapy, home health aids, and two months in rehab.

Who's gonna pay for all that? Or will John simply die because he can't afford it? Answer: Something ELSE is going to happen, besides MA simply paying out X dollars for patient John.

What is that something else? I don't know. But I'm confident it's something else.

[Rainger99]

I am still confused. I thought Medicare Advantage worked the following way:

For every patient enrolled in UHC, Medicare pays a certain amount to UHC. This is based on your RAF rating (Risk Adjustment Factor). RAF is based on your overall health.

The average score is 1.00 and assuming that the average payment is $1000, UHC would get $1000 a month for each patient with an RAF rating of 1. If a person has a score of .8, UHC would get $800 a month and if a person had an RAF score of 1.5, UHC would get $1500 a month.

I thought that if UHC provides less care than the amount that Medicare pays each month that UHC keeps that as profit. And if UHC provides more care than the amount that Medicare pays each month, UHC has to make up the difference.

This is from the bankruptcy filing.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that 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.

In approximately August 2024, TVH became aware of a potential issue with respect
to its HCC guidance. At that time, TVH learned that it may have submitted HCC diagnosis codes that were not clinically supported or otherwise did not meet Medicare coding and payment guidance. For example, TVH engaged in a retrospective review program (in which patients’ medical histories were reviewed to identify instances in which TVH believed additional codes were supportable and could be added) that may not have been consistent with Medicare coding and payment guidance.

I think it means (but I am not sure) that if TVH assigned you a higher RAF rating, that TVH would get more per procedure so that TVH would have an incentive to assign people higher RAF scores. Do they get more procedure or do they usually have more procedures because they are in worse health?

I am not sure how this works with UHC. It seems that UHC would get more money each month also since their payment is based on RAF scores. If that is the case, does UHC owe Medicare a lot of money?

Is there someone that can explain this? A lawyer, a coder, a doctor?

Has anyone obtained their RAF score? I contacted UHC and they told me to contact TVH.

[Rainger99]

Originally Posted by OrangeBlossomBaby

If you want the answer to that, first consider the common sense answer, using a common hypothetical.

MA pays X dollars for patient John. Every month. No more, no less. And then John is found to have a brain tumor that is treatable with chemo, targeted radiation, months of physical and speech therapy, home health aids, and two months in rehab.

Who's gonna pay for all that? Or will John simply die because he can't afford it? Answer: Something ELSE is going to happen, besides MA simply paying out X dollars for patient John.

What is that something else? I don't know. But I'm confident it's something else.

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.

[OrangeBlossomBaby]

Originally Posted by golfing eagles

I think you would find the high turnover rate is due to the fact that there are just as many, if not more, physicians at TVH that are near the end of their career than those at the beginning of theirs. Young doctors tend to want to be near urban areas and suburbs with children for playmates for theirs. There is little attraction for a young family in a 55+ retirement community. Plus, the salaries are higher elsewhere.

Agreed. Thanks to the massive expansion of The Villages, there are fewer and fewer neighborhoods where young families can raise their children. Public schools are getting worse and worse while the Charter School is taking more and more children of lower-income employees of/at The Villages. Private schools are few and far between. Middleton is great, IF you work in the southern half of The Villages. But why would anyone want to commute an hour in each direction for a relatively low-paying job as a doctor, nurse, PA, receptionist, scheduler, phlebotomist, etc at TVH up in Spanish Springs?

TVH was awesome for years because it was relatively exclusive, and didn't need thousands of employees to care for tens of thousands of patients. That's all changed. It's become an enormous machine that has been pieced together with duct tape and zip-ties, and the only people who know how it's run, are getting ready to retire.

[OrangeBlossomBaby]

Originally Posted by Rainger99

I am still confused. I thought Medicare Advantage worked the following way:

For every patient enrolled in UHC, Medicare pays a certain amount to UHC. This is based on your RAF rating (Risk Adjustment Factor). RAF is based on your overall health.

The average score is 1.00 and assuming that the average payment is $1000, UHC would get $1000 a month for each patient with an RAF rating of 1. If a person has a score of .8, UHC would get $800 a month and if a person had an RAF score of 1.5, UHC would get $1500 a month.

I thought that if UHC provides less care than the amount that Medicare pays each month that UHC keeps that as profit. And if UHC provides more care than the amount that Medicare pays each month, UHC has to make up the difference.

This is from the bankruptcy filing.

TVH receives a monthly payment per member (“PMPM”) for each MA beneficiary that it treats. The PMPM amount that 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.

In approximately August 2024, TVH became aware of a potential issue with respect
to its HCC guidance. At that time, TVH learned that it may have submitted HCC diagnosis codes that were not clinically supported or otherwise did not meet Medicare coding and payment guidance. For example, TVH engaged in a retrospective review program (in which patients’ medical histories were reviewed to identify instances in which TVH believed additional codes were supportable and could be added) that may not have been consistent with Medicare coding and payment guidance.

I think it means (but I am not sure) that if TVH assigned you a higher RAF rating, that TVH would get more per procedure so that TVH would have an incentive to assign people higher RAF scores. Do they get more procedure or do they usually have more procedures because they are in worse health?

I am not sure how this works with UHC. It seems that UHC would get more money each month also since their payment is based on RAF scores. If that is the case, does UHC owe Medicare a lot of money?

Is there someone that can explain this? A lawyer, a coder, a doctor?

Has anyone obtained their RAF score? I contacted UHC and they told me to contact TVH.

That
Is
Not
What
Is
Happening.

I don't know how people can explain this to make it any more clear than has already been explained.

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.

[tophcfa]

Originally Posted by OrangeBlossomBaby

Agreed. Thanks to the massive expansion of The Villages, there are fewer and fewer neighborhoods where young families can raise their children. Public schools are getting worse and worse while the Charter School is taking more and more children of lower-income employees of/at The Villages. Private schools are few and far between. Middleton is great, IF you work in the southern half of The Villages. But why would anyone want to commute an hour in each direction for a relatively low-paying job as a doctor, nurse, PA, receptionist, scheduler, phlebotomist, etc at TVH up in Spanish Springs?

TVH was awesome for years because it was relatively exclusive, and didn't need thousands of employees to care for tens of thousands of patients. That's all changed. It's become an enormous machine that has been pieced together with duct tape and zip-ties, and the only people who know how it's run, are getting ready to retire.

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.

[Rainger99]

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.

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?

[GWilliams]

Originally Posted by Snowbirdtobe

I’ll bet there are 100 lawyers listed as being involved in the case and none of them could explain it.
How could someone hide $300,000,000 in losses from Medicare and United Health? Why would someone come along fat dumb and happy and try to buy into the mess?

They buy the loss to write off the profit=No taxes.

[biker1]

Do you know for a fact that the buyer will assume the loss? If they have a loss then they don't have a profit.

Originally Posted by GWilliams

They buy the loss to write off the profit=No taxes.

[jojo]

Curious to know who the speaker was for the philosophy club?

[CoachKandSportsguy]

Originally Posted by GWilliams

They buy the loss to write off the profit=No taxes.

possible, but in this case, buying the loss means buying the customers/physical assets. . . and the loss comes with the Medicare liability. . . if they buy the business without the Medicare liability, there is no loss, just customers and assets, assets which get revalued, and customers who start all over with billing codes and medical encounters.

usually in the purchase to use the loss, is an operating loss carry forward after a transaction has been completed. . . which I am not certain that will apply in this case, as its a continuing operating liability. . .

but i am not a tax lawyer, and don't even want to play one on TV

[Rainger99]

Originally Posted by jojo

Curious to know who the speaker was for the philosophy club?

Steve Andelman

He said that he was not a lawyer or a doctor.

[ScottFenstermaker]

There have been a number of posts concerning the manner in which TVHS is paid by United Health and the other insurers for Mecicare Part C. Several of the posts are inaccurate or speculative. To get the facts (or at least TVHS's version of them), click here and read paragraph 27: https://cases.stretto.com/public/x45...0000000204.pdf

To understand that paragraph, one must realize that TVHS is not paid by the Part C insurers for each service TVHS renders, which is the traditional Medicare Part C method. Instead, TVHS gets a monthly, per capita payment.

Warning: even after reading paragraph 27, you will not understand the calculation of the $361million claim of the US Government. That cannot be discerned on the basis of any of the filings in the bankruptcy case-- so far.