Upcoding, Unbundling, and Double-Billing
Upcoding, unbundling, and double-billing are three distinct forms of Medicare and Medicaid fraud.
"Upcoding" is the practice of using a billing code that results in a higher reimbursement rate than the level of service justifies. For example, upcoding occurs when a physician examines a patient briefly for a simple matter such as a cold but submits a bill for an hour-long complex visit; or when a pharmacist provides a patient with a low-cost generic but submits a bill for a higher-cost branded drug.
"Unbundling" refers to the practice of using two or more Current Procedural Terminology (CPT) billing codes instead of one inclusive code. It also refers to the practice of submitting multiple bills in order to obtain a higher reimbursement for tests and services that were performed within a specified time period and which should have been submitted as a single bill.
"Double billing" occurs when a provider attempts to bill Medicare / Medicaid and either a private insurance company or the patient for the same treatment, or when when two providers attempt to get paid for services rendered to the same patient for the same procedure on the same date. Double billing also occurs when a provider attempt to charge more than once for the same service, for example by billing using an individual code and again as part of a bundled set of tests.
Examples of Upcoding
The owner of a mobile dental practice, his office manager, billing manager, and four dentists employed by the practice were indicted for allegedly upcoding or billing Medicaid for more expensive services than actually provided to the patients. Click here to read more....
Dental Billing Fraud
A dentist was sentenced to 18 months in federal prison for upcoding bills to receive higher reimbursements than the procedures justified, and billing for services not reimbursable by Medicaid by using a different billing code. Click here to read more....
Home Healthcare Fraud
A medical doctor and registered nurse have been charged with billing Medicare and Medicaid for physician services that were actually provided by the nurse. Click here to read more....
Temple University agreed to pay $100,000 to settle claims that it overbilled Medicare and Medicaid for neurology services. According to the government, the university submitted claims to Medicare and Medicaid using codes that resulted in higher payments for services than the codes that should have been used based on the medical documentation supporting the services. Click here to read more....
Psychiatric Billing Fraud
A psychiatrist was arrested on grand larceny charges for allegedly billing Medicaid for 45 minutes sessions with patients when the sessions were actually shorter. Click here to read more....
Examples of Unbundling
Radiation Oncology Fraud
A physician who specializes in radiation oncology agreed to pay $486,000 to resolve allegations that he overbilled federal health care insurance programs such as Medicare, TRICARE, and the FEHB, by unbundling the billings for the treatments he provided. Click here to read more....
Examples of Double Billing
Medicaid pays nursing homes a set fee for the dental care of patients in skilled nursing facilities, and the nursing homes are supposed to pay the dentists. A recent investigation found, however, that dentists had billed Medicaid directly for services provided to almost 2,000 residents of skilled nursing facilities. This resulted in Medicaid paying twice for the same services – once when the nursing home was paid, and again when the dentist was paid directly. Click here to read more....
A former revenue manager and coding compliance officer for a radiology practice will receive a whistleblower reward of between $345,000 and $575,000 for helping the government uncover double billing of Medicare and Medicaid by his former employer and one of its clients. Click here to read more....
John Howley, Esq.
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