Medicare sets rules about medical procedures that must be billed together. If a hospital, doctor, lab, etc., tries to skirt those rules by “unbundling” those procedures and billing separately for each one, it has committed fraud.If you know about a hospice, home health provider, doctor, hospital, or any other healthcare provider that is unbundling, you can report the fraud. By filing a whistleblower lawsuit under the False Claims Act, you become a “relator” who is entitled to receive 15% to 30% of all the money that you help the Government recover.
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Ways That Providers Manipulate Coding
When a healthcare provider bills separately for every step in a procedure or test, it is “unbundling.” In order to catch unbundling, CMS has set up rudimentary programming guards that are designed to catch situation where a hospital, health care agency, nursing home, doctor, etc., is unbundling so that it can charge multiple times for a service. If the CMS computer program notes that certain codes are being billed together, it recognizes that unbundling has occurred and it kicks the bill back out. CMS then sends the bill back to the physician, home health agency, or other medical provider, to be corrected.
The program has two flaws:
- One flaw is that the program is not able to catch all of the unbundling.
- The second flaw is that unscrupulous hospitals and physician practices are figuring out ways to trick the computerized Medicare safeguards.
For instance, some healthcare providers are intentionally choosing the wrong code to describe the service that is being provided to a patient. Since the CMS program is trying to catch a different combination, it cannot catch the unbundling.
Medicare and Medicaid have no chance of stopping unbundling fraud when a doctor or hospital, etc., is putting in false codes. The federal healthcare programs and U.S. taxpayers are depending on whistleblowers who will report the unbundling.
Whistleblowers with information about doctors who are substituting fake codes so that they can unbundle can stop the fraud through an FCA lawsuit. By law these whistleblowers are entitled to receive a percentage of the money that they help the Government rake back into federal coffers.
Medicare reimburses doctors, hospitals, home health agencies, therapists, etc., each time they render a new service to a patient. In order to make the repayments uniform, Medicare has assigned a code that identifies the type of medical service that is being rendered. Then Medicare reimburses the physician, hospice, DME or other healthcare provider a certain pre-set amount per billing code.
For ease of billing, in some circumstances Medicare has set up a single code that identifies a group of intertwined services that have to be performed together. The rules are set out in the National Correct Coding Initiative, also known as the NCCI. Instead of having the doctor or hospital bill each service individually, the coder is supposed to select the billing code that covers all of the services together. Typically the rate that Medicare pays for the bundled services is less than the rate it pays if each individual service is billed separately.
When a doctor bills for each service individually, even though Centers for Medicare and Medicaid Services (CMS) has assigned a code to the services as a group, he is unbundling. Generally speaking, doctors make more when they unbundle services.
Have Knowledge That a Provider Is Unbundling? Call (404) 550-4615 Today
Request a free consultation to learn how you can prevent unbundling fraud by being a whistleblower who files a False Claims Act lawsuit. First in her class at Vanderbilt University, Lee Wallace graduated with honors from Harvard Law School. She is passionate about representing whistleblowers who are interested in stopping fraud.
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