Upcoding, Unbundling, Unnecessary Treatment And The False Claims Act
Last updated on August 25, 2026
Every year, Medicare and Medicaid pay out billions in reimbursements and other submitted bills. The False Claims Act is the primary weapon the federal government uses to identify fraudulent billing and to stop it. Fischer Legal Group works with Medicare/Medicaid fraud whistleblowers in every kind of case involving fraudulent billing.
Understanding Different Types Of Fraudulent Billing Practices
Upcoding
All medical billing is coded to explain the nature of the services provided. But providers frequently submit coding that incorrectly identifies these services. When providers or their vendors submit reimbursement claims with a higher billing code than is justified by medical charts, then the provider or vendor may have False Claims Act liability.
Unbundling
Bundling is a legitimate coding practice, in which the provider lumps related medical services together, as opposed to submitting separate claims for each service. The opposite of bundling is unbundling, in which related services are billed separately – which results in the total bill being significantly higher. Some providers engage in both practices, bundling and unbundling, guessing that the doubling of costs will not be detected. It is being detected, and our firm has worked with whistleblowers to report this practice and share in the rewards when such a case is successfully prosecuted.
Unnecessary Treatment
Aggressive patient treatment is often the result of physicians ordering unnecessary medical tests and providing unnecessary medical services. A provider can dramatically increase its profits for multiple procedures if it is reimbursed for each unnecessary test or service rendered, rather than being paid a lump sum amount per patient.
Billing For Services Not Rendered
Sometimes, physicians or other providers attempt to defraud government agencies by simply including charges for services or equipment that were never provided to a patient. The patient may not even qualify for the services that were fraudulently billed, or they may receive medical equipment that costs far less than what was billed. To cover up their activities, providers may also create fraudulent documentation related to the billing.
Recognizing These Schemes In Practice
If you work in billing, coding, or compliance, you may already sense something is wrong, but may lack the language to describe what you’re seeing. Upcoding often appears as billing software configured to default to elevated evaluation and management codes regardless of what the physician documented. You might receive instructions to apply a specific high-level code to all patients of a certain type, even when their charts show routine visits.
Unbundling reveals itself through patterns. Related procedures that should be billed together suddenly appear as separate line items across multiple patient accounts. You might notice the same combination of services consistently split apart, generating higher reimbursements than the bundled rate would allow.
Unnecessary treatment shows up in your daily work when you see physicians ordering the same battery of tests for every patient regardless of medical necessity or when you notice patterns of identical procedures across patient charts that don’t reflect individualized care. The documentation may feel formulaic or copied from patient to patient.
If these patterns sound familiar, what you’re observing has both a name and legal significance. These practices violate federal law, and you have options for reporting them safely. To understand your options, learn more about Medicare and Medicaid fraud.
Your Rights And Protections As A Whistleblower
The False Claims Act includes a qui tam provision that allows an insider with direct knowledge of fraud to file a lawsuit on the government’s behalf. You don’t report to a hotline or regulatory agency. You file a legal action as a relator, and the government investigates your claims.
Your case is filed under seal, meaning it remains confidential while the Department of Justice reviews your evidence and decides whether to intervene. During this time, your employer does not know about the lawsuit. Federal law prohibits retaliation against whistleblowers who report fraud, including termination, demotion, harassment or other adverse employment actions.
If your case succeeds, you may receive between 15% and 30% of the government’s recovery. These rewards can be substantial in cases involving systematic billing fraud. The qui tam process is complex, but it exists specifically to encourage insiders like you to come forward with evidence that the government cannot easily obtain on its own.
Take The Next Step: Contact Fischer Legal Group
Coming forward feels like a serious decision because it is. You’re considering reporting fraud you’ve witnessed at your workplace, and you need to know your rights are protected and your case will be handled with complete confidentiality.
Fischer Legal Group represents only whistleblowers – never the companies accused of fraud. We litigate False Claims Act cases and fight to protect the rights of billing professionals, compliance officers and healthcare workers who witness fraud and choose to report it. Your consultation with us is confidential, and we can help you understand whether what you’re seeing constitutes a viable case.
Contact our attorneys at 212-577-9231 or email us with specific questions about your situation. We’re here to listen and to help you take the next step.