Upcoding of Medical Services

Speak with Our Atlanta Medicare Fraud Lawyer – (404) 550-4615

According to an investigation by The Center for Public Integrity, upcoding has cost Medicare – and taxpayers — $11 billion. If you know of a hospital, doctor or medical provider that is billing for more valuable services than it is really providing (upcoding), you can make a difference for taxpayers by becoming a whistleblower who files a False Claims Act (FCA) lawsuit. Under the FCA, whistleblowers who help the Government get taxpayer money back are entitled to be paid between 15% and 30% of what the Government collects from the cheaters.

Do you have facts about a medical provider that is upcoding when it charges Medicare or Medicaid?

You may be able to file a whistleblower suit under the False Claims Act. Attorney Lee Wallace is ready to listen to your case and represent you. Lee Wallace has been named one of Georgia’s Super Lawyers®, Top 100 Lawyers, Top 50 Women Lawyers, and Top 100 Trial Lawyers. She is a fierce litigator who knows how to try and win cases involving fraud and misconduct. Read more about False Claims Act Cases involving upcoding of medical services.

Request an evaluation of your case, provided FREE of charge.

What Is Upcoding?

Medicare and Medicaid have made lists of the types of medical treatments a patient might receive, and assigned each treatment its own billing code. When a doctor (or hospital or home health agency) treats a patient, he sends Medicare and Medicaid a code that identifies what treatment he provided, and how intensive the treatment was. Medicare and Medicaid list the exact reimbursement rate for each different billing code. The reimbursement amounts vary depending on where the services are provided. For example, a 45-minute office visit has a different code than a 15-minute one, and is reimbursed at a higher rate.

Some unscrupulous medical providers are gaming this system. They have figured out that they can increase the amount they collect from Medicare and Medicaid just by selecting a different code — that pays more — when they bill for treating a patient. A medical provider that picks a code that carries a higher reimbursement rate, even though it does not describe the service that was actually provided to the patient, is “upcoding.” Upcoding defrauds U.S. taxpayers and is illegal.

Unfortunately, upcoding is occurring in virtually every type of medical setting, ranging from:

  • Individual doctors
  • Physician practices
  • Hospitals
  • Home health agencies
  • Rehab centers
  • Nursing homes
  • Therapists of all types
  • DME suppliers

How Widespread Is Upcoding?

In its report, How Doctors and Hospitals Have Collected Billions in Questionable Medicare Fees, the Center for Public Integrity says that upcoding has become widespread in the past ten years. It says that medical providers have increasingly chosen more expensive codes, “despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.”

For example, many patients would be surprised to learn that doctors claim to be spending more and more time with each individual patient – at least if you look at the billing codes the doctors have selected! An office visit to a doctor can be reimbursed at 5 different levels, depending on the complexity of the treatment given and the length of time that the doctor spends with the patient. The investigation found that in the year 2008, 7500 doctors claimed that ¾ of all visits to their offices were complex and lengthy enough to merit billing under the highest two levels.

The Center believes that Medicare has overspent by $11 billion due to inappropriate upcoding. According to the report, Medicare experts are concerned that the problem is going to increase as doctors switch to using “electronic health records, which make it easy to create detailed patient files with just a few mouse clicks.”

You Can Help Stop Upcoding – Report Fraud Today

To find out more about blowing the whistle on upcoding, get in touch with The Wallace Law Firm today and we can meet with you. We’ll review the specifics of your upcoding case and walk you through the claims process.

Tell us about the upcoding instances you’ve witnessed. Call our firm at (404) 550-4615.