Upcoding, Unbundling, Unnecessary Treatment and The False Claims Act

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 face charges.

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.

What Can I Do If I See This Activity at My Workplace?

Are you aware of upcoding, false billing and billing for unnecessary treatment where you work? The attorneys at Fischer Legal Group are happy to answer your specific questions about your situation and the steps you can take. Contact our lawyers at 212-577-9231 or email us specific questions you may have.