The Villages Health System, a healthcare provider group headquartered in The Villages, Florida, has agreed to a $541.5 million settlement to resolve self-disclosed allegations that it violated the False Claims Act by submitting false diagnosis codes to increase payments it received from the Medicare Advantage programme.
Under the Medicare Advantage Programme, aka Medicare Part C, Medicare beneficiaries may opt out of traditional Medicare and enrol in private health plans offered by insurance companies known as Medicare Advantage Organisations.
The Centres for Medicare & Medicaid Services pays the MAOs a fixed monthly amount for each Medicare beneficiary enrolled in their plans. CMS adjusts these monthly payments to account for various “risk” factors that affect a beneficiary’s expected health expenditures.
In general, CMS pays MAOs more for sicker beneficiaries expected to incur higher healthcare costs and less for healthier beneficiaries expected to incur lower costs. To make these “risk adjustments”, CMS collects medical diagnosis codes from the MAOs.
The diagnoses must be supported by the medical record from a face-to-face visit between a patient and a provider and, for outpatient visits, must reflect required or affected patient care, treatment, or management at the visit.
Providers generally submit diagnosis codes to MAOs, which are then submitted to CMS to increase payments.
At times, MAOs agree to pay provider groups like TVH a set percentage of what the MAO...
The Villages Health System, a healthcare provider group headquartered in The Villages, Florida, has agreed to a $541.5 million settlement to resolve self-disclosed allegations that it violated the...