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Getting the latest healthcare news for you
Getting the latest healthcare news for you
A Central Florida provider is paying big for gaming Medicare. The Villages Health (TVH) agreed to a $541.5M DOJ settlement after submitting fake diagnosis codes for Medicare Advantage patients from 2020 to 2024 to inflate reimbursements. The company self-disclosed the fraud before filing for bankruptcy, and was later acquired by Humana for $68M.
A Central Florida provider is paying big for gaming Medicare.
The Villages Health (TVH) has agreed to a $541.5 million settlement with the Department of Justice after submitting fabricated diagnosis codes for Medicare Advantage (MA) patients between 2020 and 2024. The company altered patient medical records — sometimes years after actual visits — to insert unsupported codes for conditions like severe obesity, blood defects, and immunodeficiency, all to inflate risk scores and boost reimbursements from insurers including Humana, UnitedHealthcare, and Blue Cross Blue Shield of Florida. By 2024, roughly half of TVH's patient codes were unsupported.
TVH self-disclosed the overbilling to federal authorities at the end of 2024 before filing for bankruptcy. That cooperation earned it credit toward a reduced settlement. Humana subsequently acquired TVH for $68 million, and insurers that benefited from the inflated payments are also returning overpayments to the government.
By the Numbers:
Why it matters: This case spotlights the systemic upcoding problem in Medicare Advantage, which is costing taxpayers tens of billions annually. As MA enrollment grows and Medicare faces financial strain, expect regulators to intensify scrutiny of both insurers and the providers they contract with.
