Upcoding of Medical Services Under the False Claims Act

Medical providers have bilked U.S. taxpayers out of $11 billion by upcoding the services they provide, according to an investigation by the Center for Public Integrity. If you have information about a doctor, hospital, home health agency or other medical provider that is upcoding, you can help Medicare and Medicaid recover millions for U.S. taxpayers. Additionally, as a whistleblower who helps the Government recover money under the False Claims Act (FCA), you will be entitled to 15% to 30% of the amount you helped the U.S. recover.

To find out more about being a whistleblower who helps stop fraudulent upcoding, feel free to contact our firm. Attorney Lee Wallace is our lead attorney, and she has been named one of the Top 100 Trial Lawyers and Legal Elite by Georgia Trend Magazine. We welcome clients from all across the country.

Get started by calling us at (404) 550-4615 today.

Billing Code Creep

Medicare has adopted “billing codes” that describe the services that physicians, hospitals, home health agencies, nursing homes, therapists, hospices, DME providers, etc., provide. Medicare has a rate schedule that shows just how much it will reimburse the healthcare provider for a particular billing code.

Medicare is battling “billing code creep,” however. Medical providers have figured out that the quickest way to get more money from Medicare and Medicaid is to use codes that have a higher reimbursement rate. This includes when a medical provider bills a code that will get more reimbursement from Medicare, even though the code does not fit what actually happening. This is known as “upcoding.”

Legal Cases of Medical Service Upcoding

The Government is serious about stopping upcoding, and it has a string of FCA cases to prove it.

  • In December 2000, HCA – The Healthcare Company – agreed to pay the government $840 million in fines, damages and penalties for upcoding and other violations. At that time, the amount was the largest government fraud settlement in history. The U.S. paid $151,591,500 to whistleblowers who had filed suit under the False Claims Act.A robust $403 million of the $840 million was assigned to address allegations the hospital had “upcoded” in order to increase the amount it was reimbursed by Medicare, Medicaid, TRICARE and the Federal Employees Health Benefits Program. Another $95 million of the settlement amount was directed toward claims that the company had performed irregular billing, including tests that were not medically necessary or that had not been ordered by doctors.
  • An Arizona company, Nextcare, Inc., coughed up $10 million to settle a whistleblower’s allegations that it had billed for unnecessary allergy, H1N1 virus and respiratory panel testing” and also upcoded. The whistleblower, a Former NextCare employee, took home $1.614 million as her portion of the settlement. NextCare is a nationwide network of urgent care centers.
  • In June 2014, the Government intervened (i.e., got involved in) in a whistleblower’s lawsuit against The Hospitalist Company, Inc. DOJ and the whistleblower accused the California-based company of upcoding. According to the suit, the company pressured its physician hospitalists to use higher codes than would have been justified based on the services they were providing. The suit is currently pending in federal court in Chicago.
  • Two nurse whistleblowers filed a False Claims Act suit against a Florida doctor. The nurses had worked in the physician’s clinic, Sarasota Pain associates. The nurses said that Dr. Chun was upcoding on his bills to Medicare, sending in claims for complex, comprehensive procedures, when in fact he was simply doing routine work such as refilling pain medication pumps that had been previously implanted in a patient. The physician paid the Government $750,000 to resolve the accusations in the FCA lawsuit.

In each of these cases, the Government found out about the upcoding fraud through a whistleblower who refused to stand by while healthcare providers ripped off federal and state healthcare programs.

Representing Whistleblowers for 25+ Years

If you know about upcoding fraud, talk to our Atlanta medical upcoding lawyer today. Lee Wallace puts her 25 years of experience to work for whistleblowers who are willing to try to stop the epidemic of upcoding that is draining federal healthcare programs such as Medicare, Medicaid, TRICARE, the Railroad Retirement Medicare Program, CHAMPUS and the Federal Employees Healthcare Program.

Stop upcoding fraud with our help today. Contact (404) 550-4615.