[tophcfa]

Originally Posted by CoachKandSportsguy

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.

And auditing for coding accuracy is not the same as having their financials audited. Since TVH is not a public entity, having their financials audited is optional, unless required by those extending credit to them.

[mtdjed]

Originally Posted by Rainger99

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

Follow the money. I am on traditional Medicare with a supplement. Last year I paid Medicare Part B $175/Month and my supplement was about $200 a month with a yearly Deductible of $240 and co-pays of $20 per visit. Not much opportunity for me to overcharge.

Providers must the use government CMS provided diagnostic codes which define how much they will be paid. Surely some providers may abuse the codes but there are two levels of authority above (CMS and Supplement Plan) to monitor.

About the only giveaway is Health Cub membership free which my supplement provides.

That is OK with me, as it is my choice and we happen to use. If it wasn't OK , I would be feeling that I was being overcharged by $60 a month.

With Medicare Advantage most of the control is transferred to the Medicare Advantage. They establish the Price of support, establish provider payments, and feedback to Medicare.

For failure I would say that the Medicare Provider is the Guilty party. They did not do their job.

[Rainger99]

According to data from the Medicare Payment Advisory Commission (MedPAC) and other analyses, Medicare's average annual spending per beneficiary in traditional Medicare is approximately $12,000 to $14,000.

Estimates from MedPAC (2024) suggest that Medicare Advantage plans cost Medicare about 22% more than traditional Medicare, implying an average annual cost of approximately $14,500 to $16,000 per enrollee in 2024.

[mraines]

Originally Posted by JeepsterGlenn

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


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?

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

[Stu from NYC]

Originally Posted by mraines

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

Takes a special kind of talent to do this in huge amounts.

[Topspinmo]

Originally Posted by OrangeBlossomBaby

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.

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

[OrangeBlossomBaby]

Originally Posted by Topspinmo

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

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.

[Topspinmo]

Originally Posted by OrangeBlossomBaby

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.

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

[golfing eagles]

Originally Posted by Topspinmo

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

It went wherever it went. Don't look at this as "extra money" separate from day to day operations. This was the revenue that they expected and believed was correct to receive, so it went to expansion, equipment, additional personnel, salaries, utilities, paving the parking lot, whatever. Their own outside auditors believed the coding was correct. NO FRAUD. NO CRIMINAL INTENT. NO CHARGES. NO INVESTIGATION. NO SLUSH FUND UNDER THE CEO'S MATTRESS. JUST A MISTAKE/DIFFERENCE OF OPINION ON CODING. Unfortunately for TVH, CMS gets the last opinion.

[Joecooool]

Originally Posted by OrangeBlossomBaby

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.

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

[golfing eagles]

Originally Posted by Joecooool

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

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.

[Stu from NYC]

Originally Posted by golfing eagles

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.

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.

[golfing eagles]

Originally Posted by Stu from NYC

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.

Of course, and that also balances the books. Did the owners of TVH make money? I don't know but it's likely. If you look at the bankruptcy filing, you'll see that many of the physicians are small shareholders, like 0.0025% each, but they have not received a penny from that share of ownership. But my point is that the money received from the so-called overbilling is not extra---it was simply what they expected and no one disagreed--not their outside auditors, not CMS----until.............and we all know the rest so far.

[Rainger99]

Originally Posted by OrangeBlossomBaby

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.

But in your example, Advantage covers it. As I understand it, Advantage pays claims out of their capitation payment. If the payment per patient is less than the capitation payment, Advantage pockets the money. If they pay more, Advantage loses money. That is why Advantage has an incentive to deny claims. See the posting about the doctor trying to get authorization from UHC for a procedure

Medicare wasn't defrauded - Advantage was. Why isn't UHC on of the biggest creditors?

[Rainger99]

Originally Posted by golfing eagles

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.

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?