[tophcfa]

Originally Posted by spinner1001

That source is not necessarily the sole source of MA-related revenues TVH might receive. As I said, Medicare Advantage is complex. It’s not a simple HMO capitation model for medical clinics. Incentive bonuses and shared savings payments from CMS are among other possible sources of revenue for a MA clinic.

Anything specific about TVH is speculation since the records are not public.

TVH aside, is it safe to assume some of the revenue generated from upcoding is used by the Medicare Advantage Insurers to subsidize stuff like little to no monthly subscriber premiums, dental, hearing, vision, and other free stuff like health club memberships that aren’t available to those on traditional Medicare with a supplemental plan? It brings to mind the old adage, “if something seems too good to be true, then it’s most likely too good to be true”! There has to be a reason that Medicare pays, on average, 22% more per person on Advantage plans than traditional Medicare, despite the fact that people on traditional Medicare tend to be sicker and require more care? And if that is in fact the case, is it safe to expect the cost of Advantage plan premiums to increase and/or the benefits not available to traditional Medicare to begin to disappear?

[BrianL99]

Originally Posted by spinner1001

Anything specific about TVH is speculation since the records are not public.

Most of it is subject to the Federal Freedom of Information act, so the finances are public, as is everything involving the so-call "fraud", once that's settled.

[Snowbirdtobe]

The bankruptcy proceedings open up many records. The amount of debt and the top debters are available on the court website. Even the Daily Sunny could find it. The pro-forma DIP plan is also in court documents. What the new operator of the facilities will do with the business is not public but may be revealed in court documents.
The stalking horse should find out where the money went so they don't become a Judas Goat.

I signed up for TVH when it first opened and in a year was so disappointed that I moved back to Medicare Plan F.

[CoachKandSportsguy]

Originally Posted by BrianL99

Most of it is subject to the Federal Freedom of Information act, so the finances are public, as is everything involving the so-call "fraud", once that's settled.

The medical records by individual which was over coded is not available under the freedom of information act, that would be a patient privacy issue.

so even if they were available, not sure you can determine which was uploaded and which wasn't to get through the formulas to get to the overpayment amount. . .

[Rainger99]

Has the Morse family made any statement on the bankruptcy and the billing errors

The issue does not make the Villages look good so I would think that their public relations firm would try to get ahead of the issue.

[BrianL99]

Originally Posted by CoachKandSportsguy

The medical records by individual which was over coded is not available under the freedom of information act, that would be a patient privacy issue.

so even if they were available, not sure you can determine which was uploaded and which wasn't to get through the formulas to get to the overpayment amount. . .

It should all be available via FOI, other than patient names. If it was submitted to Medicare, it's a public document and subject to disclosure, with identifying information redacted.

There have been some posters who should have reasonable knowledge of what's been going on with TVH, but some media reports, suggest TVH's actions were more nefarious. I have no real clue how all this happened, but $361M seems far beyond a "misunderstanding" or "computer glitch". I have a former golfing partner who lost his medical license and served a significant prison sentence, for "over billing Medicare" and that was 7-8 years ago, before the Feds got real serious about routing out abuse.

"The Villages Health System LLC, which operates clinics for retirees living in the Villages in Central Florida, said in a July 3 court filing that it logged patient diagnoses that “were not clinically supported or otherwise did not meet Medicare coding and payment guidance.”"

(Villages Health System Sees $350 Million in Medicare Overcharges)

Call me crazy, but that sounds dangerously close to an admission of guilt.

[golfing eagles]

Villages Health where did all the money go?

A legitimate question. Let me speculate with an analogy, since I doubt it is under the CEO's mattress:

You own Snowbird Enterprises, a company that manufactures and sells widgets solely to the US Government at $2.00/widget. You start with one factory and a staff of 6, but your business grows fairly rapidly due to the demand for widgets. You make some profit, and use that to build more factories, hire more people and attract new professional widget makers. Maybe there's some cash, maybe not, since the books pretty much balance. And because you were dealing with a government bureaucracy, both when setting up your business and as an ongoing concern, you hired outside consultants to make sure you were doing everything right, including the pricing of widgets. Those auditors tell you all along that everything is being done by the book.

Time goes by, like 12 years, and you decide to sell your widget business, so you start negotiating with Widget Mart. To your dismay, they look at your widget pricing and tell you they disagree with the consultants you've hired----it is their opinion that you've been manufacturing type xyz5 widgets, which the government is only allowed, by law, to pay $1.50 each. You look at the difference between xyz5 and the xyz4 widgets that you've been selling, and it still isn't clear who's right since the definition of these widgets is extremely vague and subject to interpretation. So you report to the government that you MAY have been charging too much for widgets. And of course that agency agrees that they paid too much and you now owe them $360 million.

But you don't have $360 million, not even close. You have buildings, and equipment that is generally only good for making widgets, payroll, and bills for utilities and supplies, but no cash---because that's where the money went

Simplistic example, but the general message is accurate.

[golfing eagles]

Originally Posted by BrianL99

.......

"The Villages Health System LLC, which operates clinics for retirees living in the Villages in Central Florida, said in a July 3 court filing that it logged patient diagnoses that “were not clinically supported or otherwise did not meet Medicare coding and payment guidance.”"

(Villages Health System Sees $350 Million in Medicare Overcharges)

Call me crazy, but that sounds dangerously close to an admission of guilt.

It sounds like an admission that a mistake was made, nothing more. Actually, it may indicate nothing more than a difference of opinion on exactly what the diagnostic and billing codes actually require to meet the criteria set forth.

[dewilson58]

Originally Posted by golfing eagles

Villages Health where did all the money go?

A legitimate question. Let me speculate with an analogy, since I doubt it is under the CEO's mattress: .................................................. .

That's one possibility, I heard it was because all the hospital patients were only drinking water and not buying off the menu.

[golfing eagles]

Originally Posted by dewilson58

That's one possibility, I heard it was because all the hospital patients were only drinking water and not buying off the menu.

That was a subsidiary of TVH-----Katie Belle's

[JeepsterGlenn]

Originally Posted by spinner1001

The information is not in the public domain and likely will never be. I guess much (but not all) of the overpayments was/is with the MA insurance company(ies). See my first post how TVH health might be legally responsible for reimbursement. Only insiders and the government know. Others don’t.

I understand that inquiring minds want to know details but they likely will never get information. Come to think of it, there might be an opportunity for a new TV series about all of this.

================================================== =========================


Patients most likely also overpaid TVH facilities and doctors through their deductibles and copays due to the inflated procedure codes. For example if the procedure should have been coded to pay $100 and instead was coded to pay $200. Then the patient pays $200 in their deductible up to max deductible (and/or a percent of the $200 in their copay amount). Will these overpayments get reimbursements?

[BrianL99]

Originally Posted by BrianL99

"The Villages Health System LLC, which operates clinics for retirees living in the Villages in Central Florida, said in a July 3 court filing that it logged patient diagnoses that “were not clinically supported or otherwise did not meet Medicare coding and payment guidance.”"

(Villages Health System Sees $350 Million in Medicare Overcharges)

Call me crazy, but that sounds dangerously close to an admission of guilt.

Originally Posted by golfing eagles

It sounds like an admission that a mistake was made, nothing more. Actually, it may indicate nothing more than a difference of opinion on exactly what the diagnostic and billing codes actually require to meet the criteria set forth.

I know nothing about being a doctor, but surely have some experience with government requirements and "forms".

I get what you're saying and it makes sense, other than the shear magnitude of the error. It seems unlikely that such a disagreement over interpretation or standards, could amass a discrepancy of $360,000,000. To quote Everett Dirksen, "a million here, a million there ... next thing you know, we're talking about real money".

[Altavia]

Originally Posted by golfing eagles

It sounds like an admission that a mistake was made, nothing more. Actually, it may indicate nothing more than a difference of opinion on exactly what the diagnostic and billing codes actually require to meet the criteria set forth.

I don't understand how an auditor who has never seen nor has access to the patient information can dispute a diagnosis?

What would the patient impact have been if treatment was based on the auditors diagnostic interpretation?

[lkagele]

Originally Posted by golfing eagles

Villages Health where did all the money go?
But you don't have $360 million, not even close. You have buildings, and equipment that is generally only good for making widgets, payroll, and bills for utilities and supplies, but no cash---because that's where the money went

Simplistic example, but the general message is accurate.

Not sure I really agree. Your theory might make sense with a business that produces products. TVH, however, provides services and the capital outlay to expand a service business is much less than is needed to expand manufacturing capabilities. The listed assets certainly don't indicate those overpayments went to purchase tangible assets.

Pfizer sold $100 billion in vaccines yet its stock went from the low 30's to the low 20's. So, just like Pfizer's profits, I think this overpayment money went somewhere it should not have.

[Joecooool]

I don't understand how some people are saying it was an over billing issue and its OK because they self reported.

What?

They get audited by the government. They probably self-reported because they knew they were going to get found out in an audit.

These Medicare Advantage Plan companies know full well what the rules and regulations are. They have legal teams, internal compliance officers, and they have to be trained and qualified to hold those positions.

No pass should be given to people who perpetrated this fraud against the American taxpayers. They need to be arrested, charged, convicted, fined, imprisoned, and then banned from ever working in the healthcare industry again.

But no way that will happen. Someone up top will make a political "donation", and all of this will be swept away with no one being held accountable.

Get caught stealing $750 worth of crap from Walmart, and you go to jail for 5 years. Defraud Medicare for hundreds of millions of dollars - and - well look what happened to Rick Scott... PolitiFact | Rick Scott '''oversaw the largest Medicare fraud''' in U.S. history, Florida Democratic Party says

It's a big club, and you ain't in it.