Originally Posted by golfing eagles (Post 2445833)

Wow, that's an easy question to answer:

1) THEY ARE NOT THIEVES
2) My posts are based on expertise in health care, generally it is nonsense that I am responding to (like now)
3) They not only had people on staff, but outside consultants, and they were told their coding was fine, which only goes to show how vague many of these diagnostic codes are.
4) THERE IS NO OFFICIAL ACCUSATION OF, NOR INVESTIGATION OF FRAUD
5) YOU don't get to send people to jail, a judge and jury does.

So, take another look at who has posted "nonsense", I would suggest you need a mirror

Originally Posted by Joecooool (Post 2446033)

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.

Originally Posted by Velvet (Post 2446034)

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

Originally Posted by golfing eagles (Post 2446049)

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

Originally Posted by Topspinmo (Post 2446055)

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?

Originally Posted by golfing eagles (Post 2446048)

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

First)...

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)

Originally Posted by golfing eagles (Post 2446048)

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)

Originally Posted by Risuli (Post 2446057)

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.

Originally Posted by BrianL99 (Post 2446058)

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.

Originally Posted by golfing eagles (Post 2446131)

same difference in this context

Originally Posted by Joecooool (Post 2446145)

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. In ANY book, that is fraud or gross incompetence.

Originally Posted by golfing eagles (Post 2446019)

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.

Originally Posted by JustSomeGuy (Post 2446169)

FYI, the developer will get 60% of the 39 Million if the sale and the bankruptcy goes through. Taxpayers lose 320,000,000.

Originally Posted by JustSomeGuy (Post 2446169)

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: I 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.