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How prevalent is medical upcoding?

Upcoding – the practice of submitting a bill to Medicare or insurance companies using codes for procedures that were more expensive than the ones actually performed – faces growing scrutiny.

Last October, HealthCare Partners Holdings, a subsidiary of one of the nation’s largest dialysis providers, DaVita, agreed to pay $270 million to settle a whistleblower’s allegation that it cheated Medicare.

Whistleblower awarded $10 million

HealthCare Partners Holdings was accused of submitting codes to insurers from 2007 to 2014 for examinations that were more expensive than those performed. DaVita did not admit fault and said most of the claims originated before DaVita bought HealthCare Partners Holdings in 2012.

The whistleblower who reported that HealthCare Partners knew that many of the diagnostic codes were unsupported will receive more than $10 million under the federal False Claims Act that rewards whistleblowers.

Upcoding increases the cost of healthcare, which is then passed along to the consumer. That means you and I pay for upcoding, which is why it’s’ important for everyone to keep an eye on their medical bills

How to spot upcoding

There are steps you can take if you suspect upcoding:

  • Check you estimate of benefits to see what services your health care provider is being billed and if they match the services you remember receiving
  • If you find a problem, ask your provider about it. They may be able to explain it or change it
  • Notify your doctor of discrepancies. Your doctor may stop referring customers to that diagnostic facility if they are crooks
  • Contact the healthcare provider and report the fraud. Check with the state Medicaid office to see how they would like you to report the fraud. If your payor is Medicare, there is a web site where you can report the abuse.

When confronting government or private insurance carriers of fraud, it’s important to have qualified, experienced representation at your side.

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