[golfing eagles]

Originally Posted by Rainger99

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?

Not what happened

[Joecooool]

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.

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.

[Rainger99]

Originally Posted by golfing eagles

Not what happened

Tell us what happened.

[golfing eagles]

Originally Posted by Joecooool

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.

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

[golfing eagles]

Originally Posted by Rainger99

Tell us what happened.

I've already explained it 3 different ways. In the last analogy, the banana company NEVER got unexpected revenue from the sale of bananas, they got the $100 they expected. Only after years of selling them at $1 each did they find out, or at least there was an opinion out there, that they should have only been charging $0.75 each

[MX rider]

Originally Posted by golfing eagles

I've already explained it 3 different ways. In the last analogy, the banana company NEVER got unexpected revenue from the sale of bananas, they got the $100 they expected. Only after years of selling them at $1 each did they find out, or at least there was an opinion out there, that they should have only been charging $0.75 each

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.

[Rainger99]

Originally Posted by golfing eagles

I've already explained it 3 different ways. In the last analogy, the banana company NEVER got unexpected revenue from the sale of bananas, they got the $100 they expected. Only after years of selling them at $1 each did they find out, or at least there was an opinion out there, that they should have only been charging $0.75 each

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?

[golfing eagles]

Originally Posted by Rainger99

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.

[OrangeBlossomBaby]

Originally Posted by Topspinmo

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

Originally Posted by Topspinmo

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

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).

[Caymus]

Originally Posted by golfing eagles

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.

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

[BrianL99]

Originally Posted by golfing eagles

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.

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.

[golfing eagles]

Originally Posted by BrianL99

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

[JustSomeGuy]

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.

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.

[Rainger99]

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.

[golfing eagles]

Originally Posted by JustSomeGuy

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.

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.