Atlanta Medical Unbundling Fraud Lawyer

Do you know about a healthcare provider that is unbundling medical services when it bills Medicare, Medicaid, or any federal healthcare program? Some providers bill separately for each little step in a medical procedure, in order to trick Medicare and Medicaid into paying more than they have agreed to pay.

If you know about a provider that is unbundling medical services, discuss whether you are able to file a whistleblower False Claims Act lawsuit. Whistleblowers can stop fraud and under the False Claims Act, they are entitled to 15% to 30% of what they help the Government recover back from the fraudsters.

Call The Wallace Law Firm, LLC today for a FREE case consult.

Examples of Unbundling Fraud

Unbundling Lab Tests

Medicare and Medicaid have found it difficult to reign in the unbundling of lab tests. CMS’s definition of an unbundled lab test is: “when a laboratory bills separately for some, or all tests, analyzed simultaneously by a single piece of equipment on a single patient specimen.” OEI-05-00-00070.

CMS says some labs are engaged in another very subtle scam. These labs offer physicians “bundles” of tests. Physicians order one of the bundles, thinking that they are getting the one they want plus some additional tests that apparently come free in the bundle. The lab has a different plan, however; the additional tests are not part of a bundle recognized by Medicare, so the lab bills the additional tests separately — even though the physician never intended to order them separately.

Unbundling Skilled Nursing Facility Charges

Before 1997, a skilled nursing facility (SNF) billed for its services, and outside suppliers were allowed to bill separately for the services they furnished directly to the patient. Under the Balanced Budget Act of 1997, a skilled nursing facility is now supposed to handle all the billing for services that its residents receive, regardless of who provides the service, i.e., the skilled nursing facility is supposed to do “consolidated billing” (CB).

CB has some exceptions. For example, doctors, and nurse practitioners and physician assistants who are working under the supervision of a physician, can bill separately for the services they personally render to the patients. Beyond these and a limited few other exceptions, unbundling is illegal for SNFs.

Cases Involving Unbundling – Violations of the False Claims Act

In March 2014, Duke University settled a False Claims Act case with the U.S. Department of Justice (DOJ), agreeing to pay $1,000,000 to resolve accusations it had defrauded the government’s healthcare programs. Duke was accused of unbundling cardiac and anesthesia services. DOJ said that the North Carolina hospital was adding a modifier “59” to the codes it used in order to unbundle services that really should have been billed together.

A healthcare provider is only supposed to use the 59 modifier in unusual situations where it is essentially treating a patient twice on the same day, for example, when the patient has injuries to two different parts of the body. The CPT manual says, “Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”

In this case, however, DOJ said that Duke was adding the 59 modifier in order to hide the fact that it was unbundling. The Government recovered the money thanks to a whistleblower who brought the FCA case. The whistleblower had been a billing coder and auditor at Duke.

Stand Up to Fraud with The Wallace Law Firm, LLC

Contact Lee Wallace today if you know about a doctor, hospice, hospital, home health agency, DME provider, or any other healthcare provider that is cheating taxpayers by unbundling when it bills Medicare and Medicaid. We are ready to put in the necessary time and work to help whistleblowers who want to stop medical providers who are unbundling their services so that they can charge extra to Medicare and Medicaid.

Give our office a call at (888) 581-9132 to begin.