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 (888) 581-9132 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
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
- 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 (888) 581-9132.