What is upcoding and why is it illegal?

When a medical professional treats a Medicare patient, the provider must report what services were provided to make sure Medicare reimburses the doctor appropriately for the services rendered. Certain conditions are more severe than others and require more costly care, which may mean that doctors can receive higher reimbursements from Medicare for treating these patients. In some cases, a healthcare provider may engage in upcoding – misreporting healthcare services or the severity of a patient’s condition, in order to receive higher reimbursement from Medicare. If you are a healthcare professional who is aware of potential upcoding in your work environment, it is vital to contact a healthcare whistleblower attorney immediately.

Whistleblower Attorneys Help Protect the integrity of the Medicare System

Medicare is the US government health insurance plan for people over the age of 65. When a medical provider provides services to an eligible Medicare patient, they submit an electronic form to Medicare that uses procedure codes (HCPCs) to tell them what services were provided. The process is efficient when providers certify their claims as true, accurate, and complete.

After submitting a claim for reimbursement, Medicare reviews the details of the claim and if approved, pays out accordingly. The Medicare system relies on the information submitted by providers. Providers are responsible for checking that they have used the correct procedure code and have performed all of their services correctly. Providers are subject to less oversight because Medicare does not have the means to double-check all information submitted. Providers must be careful to submit accurate information to maintain a good reputation and avoid being excluded from the program altogether.

What does “upcoding” mean?

Upcoding or code manipulation refers to the act of purposefully misreporting the health care services provided in order to receive higher reimbursement from the insurance programs. Upcoding is a common form of Medicare fraud that classifies treatments as being more complex or costly than what would be needed to address an individual’s needs.

Medicare may pay out more money than is necessary to providers who perform services for Medicare beneficiaries because some healthcare providers will falsely bill Medicare by giving them a service that they didn’t really perform and claiming to have done so. For instance, if a physician performs a minor chest procedure but bills Medicare using the billing code for major heart surgery, they may have engaged in upcoding fraud.

The False Claims Act (FCA) imposes liability for fraudulent “upcoding” of claims.

The False Claims Act, established in 1863 to combat fraud against the government, prohibits individuals from submitting false or fraudulent claims. Under this law, those who sue can keep a portion of what is recovered if they have knowledge of alleged Medicare fraud. The FCA also provides incentives for private-sector whistleblowing by protecting healthcare workers from certain types of retaliation for reporting in good faith.

National Healthcare Whistleblower Lawyer

Medicare fraud negatively impacts everyone, but whistleblowers are heroes that effectively protect our healthcare system. When you become aware of Medicare fraud upcoding in your workplace, you need the advice of an experienced whistleblower attorney who can ensure that your claim is fully investigated and filed promptly and accurately.

At Khurana Law Firm, P.C., we have many years of experience as national qui tam lawyers that can help fight against Medicare fraud. For a free, confidential evaluation call (888) 335-5107.