Originally Posted by golfing eagles (Post 2445364)

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.

Originally Posted by golfing eagles (Post 2445443)

And I don't understand how anyone can post that this was criminal fraud without knowing the facts or understanding the process. That's OK, as I said, the villagers are out with torches and pitchforks. I would prefer holding off on the accusation of criminal fraud until and unless the DOJ charges them and a judge/jury convicts them. But that's only American due process and presumption of innocence. Mob mentality on social media is much better :1rotfl::1rotfl::1rotfl:

Originally Posted by Snowbirdtobe (Post 2444961)

The Villages has received over $361,000,000 in over payments from the FEDS.
The bankruptcy filings has the US taxpayers or Medicare listed as an unsecured creditor due 361 Million US $. Where is that money? That is $6500 per patient.
I noticed that the rent was paid to TV. The rent looks to be 1,135,000 per month, but no rent is forecast for October, Nov, or Dec in the pro-forma DIP budget.

Originally Posted by tophcfa (Post 2445007)

- The Villages Health (TVH) ran a unique business model for a large health care provider serving predominately a senior community. Unlike just about ever other similar health care provider, TVH primary care operation has not accept traditional medicare, only specific Medicare Advantage plans.

- Upcoding, when more diagnoses than are actually present are reported to increase medicare payments, are very rare with traditional Medicare and are almost exclusively limited to home care. On the other hand, upcoding has been widely abused with Medicare Advantage plans because under MA plans, payments are made on a risk-adjusted basis meaning higher risk scores (based on reported diagnoses) lead to higher payments.

- Despite the fact that patients with traditional Medicare and supplemental plans are generally sicker and require more health care than Medicare Advantage plan holders, Medicare Advantage plans pay out, on average, 22% more per patient than those with traditional Medicare.

- Without audited financial statements, including a detailed sources and uses of funds statement, it is impossible to figure out what happened to the $$$ referenced by the author of this thread. That being said, based on the bankruptcy filing information, the amount of reported assets relative to liabilities certainly indicates the money wasn't retained in THV surplus account.

Originally Posted by tophcfa (Post 2445007)

- The Villages Health (TVH) ran a unique business model for a large health care provider serving predominately a senior community. Unlike just about ever other similar health care provider, TVH primary care operation has not accept traditional medicare, only specific Medicare Advantage plans.

- Upcoding, when more diagnoses than are actually present are reported to increase medicare payments, are very rare with traditional Medicare and are almost exclusively limited to home care. On the other hand, upcoding has been widely abused with Medicare Advantage plans because under MA plans, payments are made on a risk-adjusted basis meaning higher risk scores (based on reported diagnoses) lead to higher payments.

- Despite the fact that patients with traditional Medicare and supplemental plans are generally sicker and require more health care than Medicare Advantage plan holders, Medicare Advantage plans pay out, on average, 22% more per patient than those with traditional medicare.

- Without audited financial statements, including a detailed sources and uses of funds statement, it is impossible to figure out what happened to the $$$ referenced by the author of this thread. That being said, based on the bankruptcy filing information, the amount of reported assets relative to liabilities certainly indicates the money wasn't retained in THV surplus account.

- A Florida Bankruptcy Judge preliminarily approved a $39 million debtor-in-possession (known as DIP financing) plan for TVH. DIP financing is a last ditch effort to raise money, often when in bankruptcy proceedings, to stay in operation during restructuring. DIP lenders require extremely stringent terms to insure their capital is protected, such as hard collateral and being court selected to be the first to be paid within the debtors capital structure. Based on TVH's reported assets, there won't be much money left after paying off the DIP loan for either their other creditors and the money owed to Medicare.

- Below is a statement from Latham and Watkins, a firm hired to help CenterWell (Humana) in the acquisition of TVH Assets, while not taking on the Liabilities. One thing is for certain, CenterWell is diving into a hornets nest, as evident by the long list of attorneys with various areas of expertise, retained to guide them through this process. No one in their right mind would dive into a hornets nest without lots and lots of protection. One can only imagine how much money the health care provider will spend on attorneys fees, rather than providing health care.

The Villages Health (TVH), announced that it has entered into a "stalking horse" Asset Purchase Agreement with CenterWell Senior Primary Care, the nation's largest senior-focused value-based primary care provider. The agreement provides for CenterWell, the healthcare services business of Humana Inc., to acquire TVH's assets as a going concern, including eight primary care centers and two specialty care centers. A Court order approving the sale, following an auction process during which other parties may submit an offer to purchase TVH's assets, will be a condition of the transaction moving forward and closing.

Latham & Watkins LLP represents CenterWell in the transaction with a corporate deal team led by Washington, D.C. partner Brian Mangino and New York partner Amber Banks and New York counsel Richard Quay, with associates Alice Bradshaw, Lauren Stern, and Daniel Maggen. Advice was also provided on intellectual property matters by Washington, D.C. partner Morgan Brubaker, with associate Tyra Richmond; on healthcare regulatory matters by Washington, D.C. partners Jason Caron and Joseph Hudzik, Chicago partner Terra Reynolds, and Washington, D.C. counsel Nicole Liffrig Molife, with associates Chad Leiper, Megan Lich, Margaret Rote, and Danielle Scheer; on data privacy matters by Bay Area partner Heather Deixler, with associates Kathryn Parsons-Reponte and Priyanka Krishnamurthy Crissman; on insurance matters by Century City partner Kirsten Jackson and New York counsel Alexander Traum; on tax matters by Washington, D.C. partner Andrea Ramezan-Jackson, with associate Nolon Blaylock; on benefits matters by Washington, D.C. partner David Della Rocca and Washington, D.C. counsel Laura Szarmach, with associate Rebecca Fishbein; on labor matters by New York counsel Sandra Benjamin, with associate Jenny Bobbitt; on real estate matters by New York partner Dara Denberg and New York counsel Shira Bressler, with associate Sarah Jeon; on finance matters by New York partner Kendra Kocovsky, with associate Benedict Bussmann; on environmental matters by New York counsel David Langer, with associate Tal Carmeli; and on restructuring matters by Washington, D.C./New York partner Andrew Sorkin and Chicago partner Caroline Reckler, with associates Isaac Ashworth and Brian Rosen.

- Just reporting some relevant facts here, what actually happened to the $$ is up to ones interoperation of the facts.

Originally Posted by lawgolfer (Post 2445520)

As a retired litigation attorney, I stand in awe of CenterWell employing 39 attorneys to handle the acquisition of The Villages Health. Between the lawyers and the lender providing DIP financing, the bones of TVH will be picked clean and bleached as white as if they had laid for years in the desert.

Originally Posted by Snowbirdtobe (Post 2444961)

The Villages has received over $361,000,000 in over payments from the FEDS.
The bankruptcy filings has the US taxpayers or Medicare listed as an unsecured creditor due 361 Million US $. Where is that money? That is $6500 per patient.
I noticed that the rent was paid to TV. The rent looks to be 1,135,000 per month, but no rent is forecast for October, Nov, or Dec in the pro-forma DIP budget.

Originally Posted by lawgolfer (Post 2445520)

As a retired litigation attorney, I stand in awe of CenterWell employing 39 attorneys to handle the acquisition of The Villages Health. Between the lawyers and the lender providing DIP financing, the bones of TVH will be picked clean and bleached as white as if they had laid for years in the desert.

Originally Posted by JeepsterGlenn (Post 2445409)

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


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?

Originally Posted by Topspinmo (Post 2445478)

Funny how innocent till proven guilty works when charged. O wait, you have to get lawyer to prove yourself innocence.

Originally Posted by CoachKandSportsguy (Post 2445487)

From bing. . . whatever search engine

Beginning in 2025, CMS will conduct annual audits of every Medicare Advantage plan, which is a significant expansion from its previous practice of auditing roughly 60 plans per year.

TVH was probably too small to be one of the 60 lucky plans to be audited. .
so to assume that THV and every medicare Advantage Plan was government audited is wishful thinking. .

Originally Posted by dpmers (Post 2445447)

Traditional Medicare only pays 80% hence most of the 22% difference in payments for MA vs Traditional Medicare

Originally Posted by tophcfa (Post 2445567)

Medicare Advantage plans were created in an attempt to team up with private insurance companies, as an alternative to traditional Medicare, in an effort to save costs and help shore up the Medicare financial situation.

Originally Posted by tophcfa (Post 2445567)

It is estimated that Medicare pays 22% more for Medicare Advantage enrollees than it would have spent if those beneficiaries were enrolled in traditional Medicare. That’s an amount that translates into $83 billion for 2024 alone….The bottom line here is that something has to give with the whole Medicare Advantage program, it’s not working as intended.

Originally Posted by Rainger99 (Post 2445599)

If MA was supposed to save the government money but is actually costing more, do people expect MA to be abolished?

Originally Posted by OrangeBlossomBaby (Post 2445550)

The auditing at TVH took place in 2024.

Originally Posted by CoachKandSportsguy (Post 2445620)

most likely the first time, so the upcoding occurred for several years to get to 300+ million. However, the point of the post is that many assume that all MA plans are audited by CMS, and that is not correct.

Also, I didn't read by whom the audit was performed, CMS or independent / non CMS for TVH, but I read alot about everyone being audited by CMS. . . I doubt the Leapfrog did their audit to find the issue.

Originally Posted by Rainger99 (Post 2445599)

If MA was supposed to save the government money but is actually costing more, do people expect MA to be abolished?

Originally Posted by JeepsterGlenn (Post 2445409)

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


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?

Originally Posted by mraines (Post 2445719)

So, I guess I don't understand how you overcharge and file bankruptcy.

Originally Posted by OrangeBlossomBaby (Post 2445548)

No need for a lawyer if you're not being charged with anything.

The Government isn't charging TVH with anything. The overpayments happened in 2024, not in 2025. This isn't something new or all that recent. There is no current fraud investigation happening with TVH as a target.

Originally Posted by Topspinmo (Post 2445729)

Close to half billion in overcharging and no investigation. Priceless.

Originally Posted by OrangeBlossomBaby (Post 2445750)

None needed. It was made transparent. TVH performed an audit (it wasn't the IRS forcing them to get audited, this wasn't a government investigational audit). They caught a really large flaw in their coding processes, that resulted in millions of dollars over a 4-year period being billed to insurance, that would've been less if they'd used the correct billing code. I'll lay it out again here since it's obviously been missed from my previous post somewhere on this forum:

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

The billing department receives the notation from the doctor's office that the patient had a checkup, AND that the patient came in with a lesion they needed to discuss.

The billing department mistakes this for two separate visits, and bills P1301 and P1462, for a total of $370. The patient pays nothing since both are still covered at 100%. TVH gets paid $370.

There's no fraud. Both of these things happened, no one is lying, no one is intending to steal money from anyone. But the people in the billing office probably had never seen these as the SAME VISIT before, and had always billed it out as separate codes, and never thought they'd need to check to find out if there was a different code for that. So they did this for EVERY patient who came into the office for a checkup, with a lesion they wanted to talk to the doctor about.

Just $170 overage, but multiply that by thousands of patients, and the billing department making the same miscode for four years in a row, and you're looking at millions of dollars in erroneous coding and erroneous payouts. The patient never sees a bill, because it's all covered. And when they look at their monthly explanation of benefits, they see exactly what they experienced: they went in for a checkup. They also discussed a lesion with the doctor.

The above example is hypothetical. Insert whatever made-up code you want, and insert any similar types of errors you want. Checkup + skin lesion is mine. Full physical with EKG for patients who are planning on getting surgery, versus full physical with EKG, plus new consultation for pre-surgery.

Any time there's a visit with a combination of "things the doctor does" there's a chance that there are a few different coding options. The doctor doesn't know billing codes. That's not his job. The billing office doesn't get to see the full notes of the doctor. It's none of their business. The doctor passes the notes to the office folks, who plug in what they believe the procedure numbers are, into the patient's billing file. The billing file gets forwarded to the billing office. The billing office determines the billing code to match the procedure codes, and the system spits out a bill.

Somewhere between the doctor's input and the bill to insurance, there were consistent errors. Likely something similar to the example I made above. Procedures that are fairly routine, that would be lumped together with one code if they happened on the same visit but have two separate codes, with two different fees charged, if they happen on different visits (even if those visits are consecutive, with one only 10 minutes after the other).

The habit of miscoding whatever the procedures were, happened as a convention, not as an intention to defraud anyone.

Originally Posted by Topspinmo (Post 2445762)

All that Don’t explain where the money went, it explains how it was taken either accidentally or intentionally?

Originally Posted by OrangeBlossomBaby (Post 2445750)

None needed. It was made transparent. TVH performed an audit (it wasn't the IRS forcing them to get audited, this wasn't a government investigational audit). They caught a really large flaw in their coding processes, that resulted in millions of dollars over a 4-year period being billed to insurance, that would've been less if they'd used the correct billing code. I'll lay it out again here since it's obviously been missed from my previous post somewhere on this forum:

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.
A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

The billing department receives the notation from the doctor's office that the patient had a checkup, AND that the patient came in with a lesion they needed to discuss.

The billing department mistakes this for two separate visits, and bills P1301 and P1462, for a total of $370. The patient pays nothing since both are still covered at 100%. TVH gets paid $370.

There's no fraud. Both of these things happened, no one is lying, no one is intending to steal money from anyone. But the people in the billing office probably had never seen these as the SAME VISIT before, and had always billed it out as separate codes, and never thought they'd need to check to find out if there was a different code for that. So they did this for EVERY patient who came into the office for a checkup, with a lesion they wanted to talk to the doctor about.

Just $170 overage, but multiply that by thousands of patients, and the billing department making the same miscode for four years in a row, and you're looking at millions of dollars in erroneous coding and erroneous payouts. The patient never sees a bill, because it's all covered. And when they look at their monthly explanation of benefits, they see exactly what they experienced: they went in for a checkup. They also discussed a lesion with the doctor.

The above example is hypothetical. Insert whatever made-up code you want, and insert any similar types of errors you want. Checkup + skin lesion is mine. Full physical with EKG for patients who are planning on getting surgery, versus full physical with EKG, plus new consultation for pre-surgery.

Any time there's a visit with a combination of "things the doctor does" there's a chance that there are a few different coding options. The doctor doesn't know billing codes. That's not his job. The billing office doesn't get to see the full notes of the doctor. It's none of their business. The doctor passes the notes to the office folks, who plug in what they believe the procedure numbers are, into the patient's billing file. The billing file gets forwarded to the billing office. The billing office determines the billing code to match the procedure codes, and the system spits out a bill.

Somewhere between the doctor's input and the bill to insurance, there were consistent errors. Likely something similar to the example I made above. Procedures that are fairly routine, that would be lumped together with one code if they happened on the same visit but have two separate codes, with two different fees charged, if they happen on different visits (even if those visits are consecutive, with one only 10 minutes after the other).

The habit of miscoding whatever the procedures were, happened as a convention, not as an intention to defraud anyone.

Originally Posted by Joecooool (Post 2445766)

Are you seriously suggesting that a for-profit business didn't notice they ended up with an extra couple hundred million dollars?

Originally Posted by golfing eagles (Post 2445773)

Again, and hopefully for the last time: It was coded, it was billed, and they received the money. It was expected; it WAS NOT EXTRA. This is not really all that hard to understand. If you sell 100 bananas at $1.00 each, you receive $100. You use it to buy more bananas, build a better banana stand and go out for dinner. There is no problem until some entity comes along and says: You can only sell bananas for $0.75 in this county, you owe $100,000 for "overbilling" the last 4 years. Now you go bankrupt. There is no secret pile of cash to pay back. You have to sell your new banana stand, liquidate your inventory of bananas and hope to find a willing buyer to take over the banana business since the people need bananas. Simple.

Originally Posted by Stu from NYC (Post 2445775)

I think you are overlooking an important factor. Profits and available cash go up and granted money is spent for expansion but also salaries and dividends to the owners go up and can go up substantially.

Originally Posted by OrangeBlossomBaby (Post 2445750)

A regular checkup gets billed as P1301 - for $200. Advantage covers it, patient pays nothing.

A regular checkup that the doctor discusses a skin lesion the patient points out is billed as P1302 - also for $200. Advantage covers it, patient pays nothing.
A separate visit to the doctor because the patient is concerned about a new skin lesion is billed as P1462 - for $170. Advantage covers it, patient pays nothing.

Originally Posted by golfing eagles (Post 2445773)

Again, and hopefully for the last time: It was coded, it was billed, and they received the money. It was expected; it WAS NOT EXTRA. This is not really all that hard to understand. If you sell 100 bananas at $1.00 each, you receive $100. You use it to buy more bananas, build a better banana stand and go out for dinner. There is no problem until some entity comes along and says: You can only sell bananas for $0.75 in this county, you owe $100,000 for "overbilling" the last 4 years. Now you go bankrupt. There is no secret pile of cash to pay back. You have to sell your new banana stand, liquidate your inventory of bananas and hope to find a willing buyer to take over the banana business since the people need bananas. Simple.

Originally Posted by Rainger99 (Post 2445798)

But if you sell 100 bananas in 2020 and make $100 wouldn't you be suspicious if you sold 110 bananas in 2021 and made $200?

Originally Posted by golfing eagles (Post 2445773)

Again, and hopefully for the last time: It was coded, it was billed, and they received the money. It was expected; it WAS NOT EXTRA. This is not really all that hard to understand. If you sell 100 bananas at $1.00 each, you receive $100. You use it to buy more bananas, build a better banana stand and go out for dinner. There is no problem until some entity comes along and says: You can only sell bananas for $0.75 in this county, you owe $100,000 for "overbilling" the last 4 years. Now you go bankrupt. There is no secret pile of cash to pay back. You have to sell your new banana stand, liquidate your inventory of bananas and hope to find a willing buyer to take over the banana business since the people need bananas. Simple.

Originally Posted by golfing eagles (Post 2445815)

Not what happened

Originally Posted by Joecooool (Post 2445817)

Why are you here acting as an apologist for these thieves? You can justify it with whatever nonsense you want, but the fact remains that they had people on staff to monitor these things.

This was fraud against we Americans. And I hope those involved GO TO JAIL.

Originally Posted by Rainger99 (Post 2445820)

Tell us what happened.