[golfing eagles]

Originally Posted by jump4

I received the following message via text at 1pm yesterday:

"Dear Valued Patient,
I’m writing to let all The Villages Health (“TVH”) patients know that during a recent review of our billing procedures, we discovered a problem with some of our Medicare billing practices. As part of TVH’s absolute commitment to transparency amongst our patient community, I am sharing this information with you now that we have examined the issue, and have already started to take meaningful action to correct it. But the most important thing we want to impart to all of you is that this billing issue has in no way negatively affected any TVH patients’ medical bills or patient care.
Upon discovering a potential problem with our Medicare billing this past Fall, TVH hired outside consultants to conduct an in-depth review of our coding and billing practices. Based on our investigation, we determined that beginning in 2020, TVH implemented certain billing processes and practices that were not consistent with Medicare payment policies. This resulted in TVH receiving more money from the Medicare program than if billed correctly. With these consultants, we are now working to identify the financial impact of these billing errors and are in the process of repaying the Medicare program for any overpayments that resulted from the billing issue. In addition to starting work with relevant government agencies to return the overbilled Medicare funds, we have also already begun to implement a range of new internal safeguards to assure that an error such as this will not recur. I cannot stress enough to each and every one of our patients that this issue has in no way affected any patient treatment or medical bills. Rather, this was an internal coding issue that unintentionally resulted in inaccurate payments received by TVH for its medical care. The occurrence of these errors has since been self-reported to the proper U.S. government agencies, and we expect a smooth process as we work diligently to make right with the Medicare program itself—all with the goal of continuing to provide you with the best possible care you’ve rightfully come to expect from all of us at TVH. At TVH, our mission to provide the highest quality patient-centered care remains at the very core of all that we do. As always, we will continue to assess ways to improve our processes and services in support of our patients and our community, and we will strive to keep you as informed as possible to maintain our commitment to trust and transparency. On behalf of all of us here at The Villages Health, we wish you a happy and healthy New Year.
Sincerely, Bob Trinh Chief Executive Officer"

Was The Villages Health under some pressure to disclose this, while also attempting to bury it with a pre-holiday release? The timing of this disclosure is noteworthy as the WSJ investigatory article about Medicare Advantage Plans, published just a couple of days ago, cited a “Suspicious” case at The Villages Health. It seems likely to me that The Villages Health is one of several parties under investigation for Medicare Fraud.

Excerpts from the WSJ article:

"Like most doctors, Nicholas Jones prefers to diagnose patients after examining them. When he worked for UnitedHealth Group, though, the company frequently prepared him a checklist of potential diagnoses before he ever laid eyes on them.
UnitedHealth only did that with the Eugene, Ore., family physician’s Medicare Advantage recipients, he said, and its software wouldn’t let him move on to his next patient until he weighed in on each diagnosis.
The diagnoses were often irrelevant or wrong, Jones said. UnitedHealth sometimes suggested a hormonal condition, secondary hyperaldosteronism, that was so obscure Jones had to turn to Google for help. “I needed to look it up,” he said.
The government’s Medicare Advantage system, which uses private insurers to provide health benefits to seniors and disabled people, pays the companies based on how sick patients are, to cover the higher costs of sicker patients. Medicare calculates sickness scores from information supplied by doctors and submitted by the insurers. In the case of UnitedHealth, many of those doctors work directly for UnitedHealth.
More diagnoses make for higher scores—and larger payments. A Wall Street Journal analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers.
Patients examined by doctors working for UnitedHealth, an industry pioneer in directly employing large numbers of physicians, had some of the biggest increases in sickness scores after moving from traditional Medicare to the company’s plans, according to the Journal’s analysis of Medicare data between 2019 and 2022.
...
In a series of articles this year, the Journal has examined the practices of Medicare Advantage companies, including UnitedHealth, the largest. Among other things, the articles showed how diagnoses added by insurers increased payments from the government.

...
Suspicious patient
Chris Henretta, a UnitedHealth Medicare Advantage plan member who lives in The Villages, a retirement community in central Florida, was suspicious when his primary-care doctor diagnosed him as morbidly obese during his annual exam in October.
He is a lifelong weightlifter, plays water volleyball five times a week and has an athletic build.
“I told her I didn’t think I was obese,” Henretta said. When she recorded morbid obesity anyway, he said, he began to “suspect my doctor may have a financial incentive to portray people as higher risk.”
The diagnosis can trigger payments of about $2,400 a year to Medicare Advantage insurers.
A widely used measure to diagnose obesity, body-mass index, has been criticized for sometimes mischaracterizing muscular people as overweight. Henretta’s medical record shows that even by that standard, he didn’t qualify as morbidly obese. His BMI was 32.3 at the time of his October visit, nearly three points below the minimum threshold for morbid obesity.
Henretta’s doctor at The Villages Health, a clinic that contracts with UnitedHealth, also diagnosed him with qualitative platelet disorder, a condition that affects blood clotting.
Henretta said his doctor added the diagnosis after he agreed that his blood seemed to clot slightly more slowly after he started taking baby aspirin several years earlier. His doctor had recommended the baby aspirin after he was diagnosed, in 2021, with aortic atherosclerosis—which could trigger Medicare payments of about $2,700 a year at the time.
Dr. Rachel Bercovitz, a hematologist and professor at Northwestern University’s medical school, said aspirin inhibits platelet function, so Henretta’s doctor is “diagnosing the intended effect of the medication” as a separate disease.
A qualitative platelet disorder diagnosis can trigger extra payments of about $2,000 a year to insurers.
The Villages Health, its top executives and Henretta’s doctor didn’t respond to phone calls and emails requesting comment.
...
Like other Medicare Advantage companies, UnitedHealth also contracts with outside doctors in ways that can increase their payments when they diagnose more conditions. That includes arrangements where doctors receive a portion of the Medicare payments insurers get for their patients. Other Medicare Advantage insurers also suggest diagnoses to independent doctors examining their patients.

Full WSJ article at: wsj.com

Very interesting. 32.3 is the definition of "obese" but not "morbidly obese", which requires a BMI of 35+. And platelet dysfunction as a diagnosis for a patient on aspirin is a stretch. That being said, one patient of 1 doctor does not constitute a systemic conspiracy to defraud Medicare.