What is Upcoding Fraud? 

The healthcare industry in the United States is a trillion dollar business. Hospital care and physician services make up almost half of the total amount spent yearly on healthcare. Where there is so much money, there is opportunity for good and for fraud. 

Healthcare fraud is not a victimless crime. Many people and businesses are affected each year to the tune of tens of billions of dollars in losses. Healthcare fraud can raise insurance premiums, increase taxes, and endanger patients by exposing them to unnecessary procedures. 

What is Upcoding Fraud? 

Upcoding is a type of fraud where healthcare providers submit inaccurate billing codes to insurance companies in order to receive inflated reimbursements. These false “current procedural technology” (CPT) submissions indicate that doctors provided patients with treatments that were more complex, costly, and time-consuming than what they actually received.

Upcoding is a violation of the False Claims Act (FCA) because it defrauds federal programs like Medicare, Medicaid, and Tricare. 

Each procedure that a doctor orders or performs has a CPT code attached to it. There are thousands of these codes in existence, and sometimes the incorrect code does make its way onto forms and insurance paperwork. Incorrect coding can lead to unnecessary procedures for the patient. If incorrect coding happens frequently over time, or with a large number of patients, fraud may be able to be proven. 

An example of upcoding would be a patient coming into the doctor’s office for a 10 minute check-up, but the check-up is coded as a full 60 minute physical exam. The physical exam is more intensive than the medical check, therefore it costs more money. Coding the check-up as a physical for the increased revenue is an example of upcoding. 

The FBI is the primary agency investigating health care fraud, for both federal and private insurance programs. The FBI investigates these crimes in conjunction with:

  • Federal, State, and local agencies
  • Healthcare Fraud Prevention Partnership
  • Insurance groups such as the National Insurance Crime Bureau, the National Health Care Anti-Fraud Association, and insurance investigative services. 

What is Unbundling? 

Unbundling is a common form of upcoding. Unbundling involves billing for individual procedures that are usually performed and billed together under a single CPT code. Unbundling occurs when a healthcare provider submits each component within a CPT to Medicare, Medicaid, or the insurance provider separately. 

Unbundling creates a cost redundancy where wrongdoers can unlawfully seek reimbursement for the same procedure several times over.

Using the example above, let’s say a patient goes to see their doctor for a physical exam. The doctor notices that the patient’s blood pressure is high and schedules a follow-up for the next day. Usually this follow-up would be coded as part of the original physical exam, however the doctor bills the two visits separately to be paid for both at a higher cost. Because the doctor intentionally overcharged the patient, this is a case of unbundling. 

Like upcoding, unbundling is fraud committed against the federal government and can result in serious penalties like fines, loss of a medical license, and jail time. 

If You Are Accused of Upcoding or Unbundling…

As soon as you’ve been accused or charged with a federal upcoding healthcare violation, it is time to involve the help of a trusted criminal defense lawyer. A professional lawyer with experience in the area of healthcare violations will help you understand the charges against you, and investigate to make sure they are valid. Navigating through the process of these charges is time consuming and difficult if you don’t have an experienced team behind you. 

Federal health care crimes carry harsh penalties like prison time as well as fines. The effect the fraud had on the patient or patients in question can also affect the length of the prison term and the cost of the fine. 

The Law Offices of Robert J. DeGroot will review the circumstances of your case and develop your best possible defense. With over 40 years of experience, our lawyers know how to protect your legal rights and provide the best possible outcome for your case. 

If you or someone you know if accused of healthcare fraud, including upcoding or unbundling, contact the Law Offices of Robert J. DeGroot for experienced attorneys who can help.