I understood you first explanation. lol
Not sure why some on here can't get what you're saying.
Thanks anyway for helping us understand the situation more clearly.

As far as I can tell, the over billing is only for the past four years. TVH started operating in 2012. What happened in 2021 to create the billing issues? Were they charging $.75 per banana from 2012 to 2021? And then they decided to raise the price of bananas?

The website says it has 55,000 patients. If you divide $360,000,000 by 55,000 that is about $6500 per patient or more than $1,500 per patient per year. Those bananas are more expensive than buying them at Publix.

TVH may have a perfect explosion for the billing discrepancy.

But if it is as innocent as you say, why doesn’t TVH or their lawyers explain it to us?

I said it could be innocent, even probably, but time will tell. What I've been against is posters that state it is definitely fraud and they should go to jail, when they don't have the slightest idea how this works, or they think 5 minutes on google makes them an expert.

Someone else had already explained what happened to the money. I was responding to your post, where you commented that close to half a billion was overcharged with no investigation (as quoted above).

Maybe the bankruptcy court will investigate and crawl back some of the payments.

If they've been getting $110 a bunch, for bananas that were only worth $100, they must be pretty lousy business managers if all the money is gone.

Or they have assets worth $10

Someone knew they charges were not correct and let it go... for years
 

Every year they must create a budget. First year of over charges, no matter the reason, even if everything added up, someone would have seen that they exceeded their expected office visits by 100% and revenues by a similar amount using the above example. Big red flag missed... or ignored (likely). Next year they use those over inflated "codings" to set the budget.... and so on. Funds were used (Hmmm) for salaries and offices to handle the workload of the miss coded visits. If that were the case those seeking care would have seen almost half the appointment slots unused (if the villages healthcare did not know there was an error), doctors seeing half the expected appointments and half empty waiting rooms... every year since the first miscoding (which in the example double counted appointments, half bogus).

If they used the funds for other purposes, profit, overpaid the doctors and staff or overpaid on rent and did not expand staff and doctors then the funds disappear but patients notice no over staffing. The organization "knew" something was wrong since they were doing twice the business with the same staff.

If any other non-government business did this someone would be found at fault.

If they truly thought the billings were correct then those who will still be using the "new company" should see the staff (including Doctors) reduced significantly and offices downsized or closed since they inflated the workload and income by miscoding as noted in the example above.

Someone got the hundreds of millions they can't repay and which caused the bankruptcy. Time will tell who. If they do not cut the number of Doctors and staff, then it went somewhere else and that needs to be investigated.

According to an AI search, the largest case of Medicare overcharging that wasn’t classified as a criminal matter appears to be the settlement involving Independent Health Association and its affiliate, Independent Health Corporation, announced on December 20, 2024. They agreed to pay up to $98 million to resolve allegations under the False Claims Act for knowingly submitting invalid diagnosis codes to Medicare for Medicare Advantage Plan enrollees to inflate payments. This was a civil settlement, not a criminal case, as it focused on improper billing practices without criminal charges.

Wrong, wrong and even more WRONG.

They did not believe there were "overcharges", therefore they did not exceed their expected revenue. And the "number of visits" is irrelevant with MA plans. I don't understand why this concept is so difficult to grasp, their budget was based on the LEGITIMATE expectation of revenue based on their number of patients and diagnostic mix, with outside consultants indicating that their coding was OK. There is nothing "extra". There is no slush fund or secret account. Nobody got hundreds of millions. There is no charge of fraud and no investigation because it is NOT NEEDED. Apparently, they have agreed to a settlement of what CMS considers a mistake in coding.

There are many people here that are "experts" on health care issues. There are not many agreeing with you.

Certified claims and billing staff within Medicare Advantage (MA) plans are crucial to ensuring that claims are processed accurately, in compliance with CMS regulations, and with proper documentation. Their primary responsibility is to submit and process claims by reviewing patient records to ensure that submitted claims align with diagnoses and procedures. They must verify the patient's eligibility for Medicare benefits and ensure proper coding and documentation for accurate reimbursement. These professionals are also responsible for medical coding, which is the conversion of healthcare diagnoses, procedures, medical services, and equipment into standardized codes, such as ICD-10 for diagnoses, CPT for procedures, and HCPCS for supplies. Accurate coding is essential for proper billing and reimbursement, as errors can lead to overpayment, underpayment, or potential fraud.

A key aspect of the job is managing risk adjustment, which involves assigning appropriate codes based on the health status of beneficiaries. Medicare Advantage plans rely on risk adjustment models, such as HCC (Hierarchical Condition Categories), to adjust payments according to the health conditions of beneficiaries. Claims and billing staff must ensure that the diagnoses submitted align with these models and that the documentation accurately supports the codes used. Additionally, fraud prevention is a critical responsibility, with billing staff trained to identify and prevent issues like upcoding, unbundling, and falsifying patient information. Medicare Advantage plans are held to strict fraud and abuse laws, and staff must be vigilant in ensuring compliance.

Claims and billing staff are also involved in audits and reporting, particularly in Risk Adjustment Data Validation (RADV) audits, where CMS ensures that submitted diagnoses are substantiated by medical records. Maintaining compliance with Medicare regulations (42 CFR Part 422), HIPAA privacy rules, and ongoing fraud detection efforts is essential. Regular reporting and participation in audits help ensure that the claims process remains transparent and accurate.

To ensure competency, claims and billing professionals must hold certifications that demonstrate their expertise. The Certified Professional Coder (CPC) credential from the American Academy of Professional Coders (AAPC) is one of the most recognized certifications for those involved in medical coding and billing, covering ICD-10, CPT, and HCPCS codes. Other important certifications include the Certified Coding Specialist (CCS) from AHIMA, which focuses on coding for healthcare facilities, and the Certified in Healthcare Compliance (CHC) from the Health Care Compliance Association (HCCA), which emphasizes compliance with regulatory standards. Additionally, professionals may pursue the Certified in Risk Adjustment (CRA) certification, which focuses on risk adjustment coding, and the Certified Fraud Examiner (CFE) credential to specialize in fraud detection and prevention. These certifications equip claims and billing staff with the necessary knowledge and skills to accurately process claims, prevent fraud, and ensure regulatory compliance within the Medicare Advantage system.

There are requirements to run these Medicare Advantage plans. Staff are required to be trained and certified to ensure proper coding and billing. There are THOUSANDS of these plans across the country, and the vast majority of them aren't doing what these guys did.

So it's either fraud or gross incompetence. And in either case, it doesn't need an apologist trying to brush it all under the rug.

So given everything you said, Joecooool, how did such a huge oversight (mismanagement) what ever you want to call it, happen?

I'll address the first and last sentences, it's obvious you googled, copied and pasted everything in between.

First) They probably disagree because they are NOT experts (except at google), and certainly don't have anywhere near my level of expertise

Last) I am not apologizing for anything since I have nothing to do with it. I am explaining and educating those who are not familiar with health care management. (And also ROFLing at those that paste something they googled and consider themselves knowledgeable)

Give him a few minutes, he'll need to google that

Don’t doctors practices hire people to do paperwork/coding and insurance? And if work for company on salary contract don’t company hire people to do insurance/coding collecting? If not then it’s either the doctor or company mis-coding. Plenty examples especially in Florida over year’s of practice’s and doctors being prosecuted for Medicare fraud far less money, why should this practice be any different. Intentionally or not still millions dollars and want get out of paying it back by filing bankruptcy?

There are various methods for coding. The first is "point of service"--the provider codes the visit at the same time he generates the progress note. The drawback is that the provider needs to be familiar with CPT coding. TVH does not use that method, primarily because they are not paid by CPT code. Medicare Advantage plans capitate payments by diagnostic complexity and number of patients, which is quite different from traditional Medicare.

Another method if you are large enough is to have professional coders that work for you and evaluate the documentation and assign a CPT code---again, not relevant to Advantage plans.

Many medium size practices simply outsource billing and coding to a third party, usually for about 8% of the billing.

The mess TVH finds itself in is not CPT coding (although that would apply to the specialty clinics), but with the use or misuse of ICDM-10 codes, which have a lot of ambiguity and room for interpretation. Now, were the providers stretching the limitations of the coding definitions? Maybe, but I doubt that since as salaried employees they have nothing to gain. At some higher level was the coding tweaked or even falsified? I doubt it but anything is possible. Most like they simply used an aggressive coding philosophy that CMS decided was wrong. And they don't "get out of it" by declaring bankruptcy, they declare bankruptcy because they can't pay it back.

In my opinion, the Last still stands as a valid question of either fraud or gross incompetence whether googled or not. If a simple billing error can cause your hospital to spiral into bankruptcy it would seem that proper management would have procedures in place to assure such errors are found, reported and eliminated well before your entire financial base is undermined. Again, just my opinion.

It was not a direct "Google search", I looked.

It was AI. There are a number of clues, for those familiar with AI phrasing and logic.

I am still looking for some context. Specifically, they apparently overbilled by $360MM but over how many years was that? Also, of the revenue they brought in over those number of years, what percentage is $360MM?

same difference in this context

What are you on about? You can't dispute what I put up so you want to just say it was googled? Even if it was, and it wasn't, who cares? It's still the facts, and those facts you can not dispute.

This company had paid certified professionals overcharge Medicare to the tune of $360M.

You’re still wrong, in ANY book. And you’re claiming those middle 4 paragraphs weren’t google or AI? Sorry, but the grammar, vocabulary and syntax in that post was way, way more sophisticated than anything else you’ve posted. No sale.

I trust you have much more experience in this than the rest of us but just saying wrong, wrong, wrong is not proof you are right.

The bankruptcy filing says: An internal investigation, supported by Goodwin Procter and FTI Consulting, revealed that a retrospective chart review program initiated around 2020 was inconsistent with Medicare guidelines.

We agree they have a budget each year. When setting their budget after this change, say for 2021, they must have planned for almost twice the income per claim or they exceeded budget by a tremendous amount. They had been open since 2012 so they had a good history to forecast from. Those seeing the "New" budget knew they somehow were able to double their income per patient with no other action except a change in billing practice from the previous 8 years.

Also stated in the filing is the fact that: "The program resulted in the submission of unsupported Hierarchical Condition Category (HCC) codes, which improperly inflated patient Risk Adjustment Factor (RAF) scores and, consequently, the capitated payments TVH received from Medicare Advantage plans." So the observation made that I was responding to - "

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."

Does not match this situation where they actually took the same visit say for obesity and upgraded it to morbid obesity, increasing risk factor and increasing their payment. Or they up coded asthma to COPD. They were not changing one visit as noted above as two, which would not impact the risk score and is not listed in the bankruptcy filing documents.

As far as the last part of my statement you said was wrong. The developer owns 61% of Villages health, Villages health is an "asset light" organization. They lease everything (equipment and clinics) and own little. They have little debt, except the repayment of 320 million. Their main asset is their workforce. (from the bankruptcy files themselves, available on line) In 13 weeks the bankruptcy budget shows they loss 5,000,000 plus with two months rent (1,100,000 each) not included for some reason. This loss was evidently covered by the excess billing that is no longer happening. How will the new company continue to fund the same staff with the loss of 64,000 million in revenue per year (320 million divided by 5)?

Those are the issues you do not address. Someone deliberately started a new billing process (which caused CenterWell to immediately pull out of a non binding agreement to buy last summer when they saw it) in 2020. Was this billing change intentionally improper? CenterWell knew it was improper. How is the new buyer after the bankruptcy, going to continue to employ the same people if the only asset they have is the workforce and if they need to cut costs by $64,000,000 per year (no one has the money hidden anywhere, correct?)? They can't sell assets and lease them back to reduce costs.

FYI, the developer will get 60% of the 39 Million if the sale and the bankruptcy goes through. Taxpayers lose 320,000,000. Patients will see cuts in employees. If not, then the $320,000,000 was not used to cover day to day business costs. It was a was taken out of the business. CenterWell is not going to lose 64 million a year. If they do not need to cut costs then the 320 million was take as profit or some other non-recurring payment that can just end when the improper billing ends.

How is the Developer going to end up with $24M? Typically, the Medicare claw-back would not be discharged in Bankruptcy. At a minimum, Medicare would be a priority debt and would get money from the sale, before anyone else does.

Valid questions. I hope we get answers.

I currently have UHC Advantage so I go to TVH but I am seriously considering switching to Medicare.

How easy is it to find doctors within the Villages that are not part of TVH? I would prefer not having to drive to Leesburg, Ocala, etc.

This whole thing is a very interesting real life business case study. Speculation abound. At this point no one, not on the inside, really knows if this is an innocent mistake, total incompetence, our intentional fraud. The original question from the first post in this thread, “where did all the money go”, is a valid question. Generally speaking, the money could have gone into three broad categories, or a combination there of.

1) Invested wisely back into hard assets necessary to support a growing long term business.
2) Used to both retain and attract talented employees necessary to service a rapidly growing and health care needy senior population.
3) Diverted away from the he business to benefit the controlling principles.

Bases on the available assets, relative to liabilities (many being owed back to Medicare for overpayments and associated penalties), listed in the bankruptcy filing, it’s pretty clear the money didn’t go into option #1. It’s difficult to say where the money went between options #2 and 3? Here is hoping, for the long term best interest of all Villagers needing quality local health care, the money went the path of option #3. If the money was truly spent mostly on option #2, that’s not a good thing, as that money won’t be available in the future, and a drain of quality talent could be in the near future.

As previously noted in post #37 of this thread, the bigger picture here isn’t about blame for what has happened, it’s about the availability, going forward, of enough quality health care to meet the needs of a a very rapidly growing 55+ senior citizen retirement community that already has a highly stressed health care system. This is not only extremely important for all of us Villagers extremely important health care needs, but also the value of our Villages homes. Let’s not all bury our heads in the sand and lose track of the much bigger picture. This event casts a very dark cloud over the future of health care in our community.

Is that true? TVH does not own the buildings but instead pays rent? Does anyone know who owns the buildings?

It is well known that The Developer retains ownership of all the commercial properties, and changes significant rent to the businesses that occupy them. That would include the medical clinics.

You are assuming that coding/billing somehow "changed" in 2020. The statement is ONLY that a retrospective review started looking at billing from 2020 to the present, it does not address 2012-2020. If the same billing and coding practices were in place from 2012 to 2020, your whole premise falls apart. NO adjustment in budget. No doubling the revenue. Just business as usual.

Now here's a concept I haven't considered: Many posters are considering the $361 M as "extra" and want to know where the money went. What if (hypothetical) they only broke even and without the "overpayments" they would have been in $361M of debt, ie: bankrupt a long time ago?????

What should they charge? Insignificant rent?

It appears that the developer is charging rent to himself.
I would love to listen in to those “negotiations.”

I would think that TVH would get the “family discount” from the developer.

When my family comes and visits for a week, I don’t charge them a penny. And I am not a billionaire.

That's not how business works.

The "Developer" consists of 100's of corporations and entities.

I started out this thread with the question where did all the money go? If you are a patient at TVH and the money was paid to keep the lights on expect dark buildings. If the money was used to fund lavish leaseholder improvements at Brownwood you should be fine unless the developer raises the 1,100,000 per month rent on the centers. I hate Brownwood and changed providers because St. Lukes was sending me to Brownwood for appointments. Moving out of the Brownwood care center should reduce the rent. Maybe that will be enough.

Thanks Doc, there’s the bigger picture I’ve been trying to get folks to focus on. If that’s the case, what does that say about the future of health care in the fastest growing senior citizen community on the entire planet? People need to stop worrying about the past and contemplate the future availability of quality health care in the Villages! This unfortunate event most certainly doesn’t make the future look more positive.

What tophcfa is highlighting is that

1) medicare is a very low reimbursement payment program. . most doctors and hospital systems can't survive with all the CMS requirements on just medicare reimbursements alone. That is why CMS has an additional reimbursement for improved outcomes, separate from individual encounter reimbursements. retirees have less opportunity for improved outcomes

2) most non retirement area hospitals have a mix of higher private pay insurance which is primarily employer sourced insurance, which pays a higher rate to offset the medicare rate to break even or not lose money.

3) So to stay financially solvent, taking only medicare isn't sustainable. . . upcoding with MA makes elderly patients financially viable. . . keep that in mind. .

So the problem with rapid growth of housing for long lived Medicare members, ie, the villages, can easily and quickly outstrip the hospital capacity without also planning and building simultaneously hospital capacity. This would fall on the developer, which he may or not make as a close secondary priority. .

So let's say the developer did keep up building hospital beds in the proper ratio, which health care system would lease out and operate out of the buildings if the primary reimbursement is medicare? and what's the probability that CMS will be able to pay for the reduced improved outcome potential? especially if one wants to reduce the federal deficit [b]without]/b] increasing taxes?. . . .

the whole US health care system is a financial conundrum/dilemma/enigma/paradox, which currently has no solution on the horizon. . its a damn can being kicked down the road. .

best to stay healthy and realize that there are limits to everything, there are no unlimited sources of money

Is Medicaid even less?

Yes, Medicaid is even less. That's why some doctors and clinics refuse to see, or limit, the Medicaid patients they accept. That's why long-term care homes that are mostly Medicaid residents have a reputation of being dirty and poorly staffed.

Not set up for profit
 

Key Assumptions
Patient Load Context: The 55,000 Medicare patient load refers to unique patients served annually, likely in a hospital or large healthcare system, as this aligns with the scale of the patient volume.
Revenue Basis: Revenue is derived from Medicare reimbursements, which vary by service type (e.g., inpatient, outpatient, physician services) and geographic location. I’ll use national averages for Medicare expenditures per beneficiary.
Profit Margins: Profit margins depend on operating costs, which include labor, supplies, and administrative expenses. Margins for Medicare patients are typically lower than for commercial payers due to lower reimbursement rates.
Data Sources: I’ll use data from the Centers for Medicare & Medicaid Services (CMS) and other healthcare financial reports, such as those from the American Hospital Association (AHA) and KFF, to estimate revenue and costs.
Geographic Variation: Medicare reimbursement rates vary by state, but I’ll use national averages for simplicity unless otherwise specified.
Service Mix: The patient load includes a mix of inpatient, outpatient, and physician services, typical for a hospital or integrated health system.
Estimating Revenue
Medicare Spending per Beneficiary
According to CMS data, Medicare spending per beneficiary in 2020 ranged from $8,726 (Vermont) to $13,652 (Florida), with a national average of approximately $10,000–$12,000 per beneficiary annually, depending on the year and service mix.
For 2023, total Medicare spending was $1,029.8 billion for approximately 65 million beneficiaries, yielding an average of about $15,843 per beneficiary ($1,029.8 billion ÷ 65 million). This figure includes inpatient hospital stays, outpatient services, physician services, and prescription drugs.
Adjusting for inflation and cost trends, I’ll use a conservative estimate of $14,000 per Medicare beneficiary for 2025, accounting for a mix of traditional Medicare and Medicare Advantage patients.
Revenue Calculation
For 55,000 Medicare patients:
\[
\text{Revenue} = 55,000 \times \$14,000 = \$770,000,000
\]

Estimated Annual Revenue: Approximately $770 million.
Revenue Breakdown by Service Type
Hospital Expenditures: In 2023, hospital expenditures accounted for 37% of Medicare spending. For $770 million in total revenue, this translates to roughly $285 million for hospital services (inpatient and outpatient).
Physician and Clinical Services: These accounted for 25% of Medicare spending, or about $192.5 million.
Prescription Drugs: These accounted for 14% of Medicare spending, or about $107.8 million.
Other Services: The remaining 24% (e.g., home health, skilled nursing) contributes approximately $184.7 million.
This breakdown assumes the patient load includes a typical mix of services. If the organization specializes (e.g., only outpatient care), the revenue distribution would shift.
Estimating Profit
Operating Costs
Hospital Costs: According to Definitive Healthcare, the average hospital operating expense in 2022 was $230.5 million for an average net patient revenue of $223.7 million, suggesting expenses often exceed or closely match revenue.
Medicare Underpayment: The AHA reports that in 2023, Medicare reimbursed hospitals at 83 cents for every dollar spent, resulting in a 17% underpayment rate. For $285 million in hospital revenue, this implies costs of approximately:
\[
\text{Costs} = \frac{\$285,000,000}{0.83} \approx \$343,373,494
\]

Thus, hospital services alone could result in a loss of about $58.4 million annually for Medicare patients.
Physician and Other Services: Physician services and outpatient care may have slightly better margins, but Medicare reimbursements still typically fall short of costs. Assuming a similar 17% underpayment rate across all services for simplicity:
\[
\text{Total Costs} = \frac{\$770,000,000}{0.83} \approx \$927,710,843
\]

Total Operating Costs: Approximately $928 million.
Profit Calculation
Net Operating Margin:
\[
\text{Profit} = \text{Revenue} - \text{Costs} = \$770,000,000 - \$927,710,843 \approx -\$157,710,843
\]

Estimated Annual Profit (Loss): A loss of approximately $157.7 million.
Adjusting for Real-World Margins
Hospital Margins: KFF reports that hospital operating margins in 2023 averaged 5.2% for all payers but were lower for hospitals with high Medicare patient shares (e.g., 3.1% for rural hospitals).
Medicare-Specific Margins: Medicare patients typically yield negative or near-zero margins due to underpayment. For-profit hospitals may achieve slightly positive margins (e.g., 0.3% for 340B program drugs), but nonprofit and public hospitals often face losses.
Alternative Scenario: If the organization optimizes costs (e.g., through efficient staffing or participation in programs like 340B), it might reduce the loss. For example, assuming a 5% operating margin on $770 million:
\[
\text{Profit} = \$770,000,000 \times 0.05 = \$38,500,000
\]

However, achieving a positive margin with Medicare patients alone is challenging without commercial payer revenue to offset losses.
Key Factors Affecting Revenue and Profit
Payer Mix: Hospitals with a higher proportion of commercial payers (who pay 254% of Medicare rates on average) can offset Medicare losses. A facility serving only Medicare patients is likely to operate at a loss.
Medicare Advantage (MA): MA plans, which cover about half of Medicare beneficiaries, often have lower reimbursement rates and stricter utilization controls (e.g., prior authorization), reducing revenue and increasing administrative costs.
Geographic Variation: Revenue per patient varies significantly (e.g., $13,652 in Florida vs. $8,726 in Vermont in 2020). Higher-cost regions may yield more revenue but also face higher operating costs.
Service Intensity: Patients with chronic conditions or higher acuity (e.g., heart failure, diabetes) increase costs due to longer stays and more intensive care.
340B Program: Participation in the 340B drug discount program can boost profits for outpatient drug administration, with estimated profits of $1.9 billion across all 340B hospitals in 2016 for Medicare Part B drugs.
Limitations
Data Gaps: The exact service mix, facility type, and geographic location are unspecified, so national averages may not reflect local realities.
Cost Variability: Operating costs vary widely based on labor markets, facility size, and efficiency. The 17% underpayment rate is an aggregate estimate and may not apply uniformly.
Medicare Advantage Impact: MA plans’ lower reimbursements and administrative burdens could reduce revenue and margins further than estimated.
Time Lag: Data from 2023 and earlier may not fully reflect 2025 reimbursement rates or cost trends.
Final Answer
Expected Revenue: Approximately $770 million annually for 55,000 Medicare patients, based on an average of $14,000 per beneficiary.
Expected Profit (Loss): Likely a loss of $157.7 million annually, assuming Medicare reimburses 83% of costs. In an optimistic scenario with cost optimization, a small positive margin (e.g., $38.5 million) is possible but unlikely without commercial payer revenue or special programs like 340B.

According to this AI analysis, the Developer is the dumbest person on earth, for thinking he could make money in the Healthcare business, in The Villages.

It's simply amazing that someone so dumb, was able to amass a fortune that exceeds $4 BILLION dollars.

or he could afford the loss leader as a special marketing draw to the housing development side, which would be not unreasonable. . . given the arrogance of the hiring the puppets and using political ties to get favorable rulings in the FL gubmint, finding ways to upcode for more money is not an unreasonable stretch of belief in one's total control of the area. . .

seen many very successful business owners believe they can control way more than they actually can. .