As we have all read by now the billing errors at The Villages Health (TVH) began in 2020, when the practice implemented certain billing processes inconsistent with Medicare payment policies, resulting in the receipt of more money than legally due. TVH discovered the issue in the fall of 2024 and hired outside consultants to conduct a review. TVH ended up facing over $350 million in Medicare overpayments.
It appears that these billing errors included diagnoses that were submitted to Medicare without the proper clinical documentation. In many cases, patient charts were amended after the 90-day CMS deadline, or diagnoses were listed without active symptoms, evaluations, or treatments. When billing Medicare (especially Medicare Advantage plans) the regulatory criteria must be stringently followed including having each diagnosis clearly supported by patient records.
Healthcare organizations that participate in federal programs like Medicare are legally required to have an effective compliance program in place. This program, among other things, must include internal monitoring and auditing systems to check for compliance with billing rules. Due to the ever-changing nature of regulations, a constant, ongoing review process and risk audits are essential to prevent billing errors, fraud, and abuse.
A primary reason for this is so that the entity can proactively identify and fix issues that external auditors would likely find, minimizing overpayment errors…