Billing Fraud: Upcoding and Unbundling
What are upcoding and unbundling?
Upcoding and unbundling are two common types of medical billing fraud. They each involve fraudulent manipulation of medical billing codes (“CPT codes”) to obtain a higher level of reimbursement from Medicare, Medicaid, or other government insurers, than warranted for the medical service or procedure provided. By engaging in upcoding and unbundling, providers enrich themselves at the expense of the taxpayers, who bear the added costs to Medicare, Medicaid and other government healthcare programs.
Upcoding occurs when healthcare providers bill for more extensive — and consequently, more expensive — services or procedures than what they actually performed on the patient. Examples of upcoding include a medical practice billing for a higher level of care at an office visit than what actually occurred, or billing for a physician service when the service was actually performed by a physician assistant, without supervision.
Unbundling occurs when healthcare providers charge procedures or services that commonly take place together — such as a comprehensive metabolic panel that analyzes 14 different blood components — as separate procedures or services, often with a coding modifier, in order to obtain a higher reimbursement. Unbundling is a form of fraud because procedures or services that are performed together are often required by federal or state law to be billed as a bundle – except in limited circumstances. Unbundling enables healthcare providers to fraudulently increase their reimbursements, receiving a higher rate than what they are legally entitled to.
Why are upcoding and unbundling illegal?
Put simply, upcoding and unbundling defraud money from Medicare and Medicaid. When upcoding or unbundling occurs, these programs reimburse providers more than they are entitled to receive.
Upcoding and unbundling can be difficult to detect. That’s because fraudsters often take care to submit false reimbursements that appear plausible enough to evade detection.
What can whistleblowers do?
Given the complexities of the healthcare billing system, whistleblowers are crucial to uncovering and putting an end to upcoding and unbundling fraud. The FCA enables people with original and non-public information of fraud being committed against federally-funded healthcare programs, such as Medicare and Medicaid, to come forward on a voluntary basis and potentially receive a portion of any settlement or judgement that comes as a result of the action. Whistleblowers are often insiders of healthcare entities who discover that their employers are billing for more than what they actually received, often on a systemic and repeated basis.
The FCA extends protections to whistleblowers who speak up against fraudulent upcoding and unbundling practices. People with knowledge of upcoding or unbundling practices may benefit from consulting with an experienced attorney. Kessler Topaz, as one of the largest plaintiff’s firms in the nation, has a long track record of successfully fighting healthcare fraud. Our whistleblower team is comprised of experienced attorneys who have dedicated their careers to representing whistleblowers against some of the largest healthcare companies in the world. Stepping forward and presenting knowledge of such schemes takes courage. The experienced team of whistleblower attorneys at Kessler Topaz can assist potential whistleblowers throughout the process. Consultations are free and confidential.