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What Is Upcoding? Do I Need a Medicare Fraud Attorney?

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If you suspect something questionable on your medicare bill, a service that is listed as more expensive than you were quoted, for example – and it seems like a simple error – contact your provider to see if it can be amended. If your provider tells you it’s all fine and you suspect misconduct, you may need to take further action. You might have encountered a piece of upcoding, but do you need a medicare fraud attorney

What Is Upcoding?

Upcoding is just one of many types of Medicare fraud, which involves using a billing code that results in a higher reimbursement than one that is merited. For example, a doctor may examine you only briefly for a code but the bill suggests she’s been there for an hour, chatting with you about a complex procedure. Another example may be that you are given a low-cost drug but you see your doctor has billed you for an expensive drug that was never provided. The discrepancy in billing may allow your medical provider to defraud the government by pocketing the extra cash.

Medical Codes Explained

Each procedure in a doctor’s office, hospital, dental office, and so forth has a code attached to it called a CPT code or Current Procedural Terminology. Some codes are bundled such as an appendectomy, for example, and some items are billed individually, such as for that one super-strength Tylenol.

Codes allow doctors to bill your insurance company or a government funding program like Medicare or Medicaid. Basically, it’s a way to bill the payer, just as you’d see items listed on a restaurant receipt. When you go out to eat, if you’d ordered the $10 spaghetti bolognese and you see a $25 steak on your bill, you’d definitely question it.

However, the complicated nature of medical billing often causes patients to miss when they’ve been overcharged – or when Medicare has been overcharged – which is why it’s so important that patients notice and stop fraud in its tracks.

How Can Upcoding Hurt You?

When it comes to upcoding, you may think, “Okay, it’s no big deal. It’s not affecting me,” but you’d be misguided. Your future care could be impacted by the codes used for your medical billing.

For example, if you go to the doctor with heart palpitations, your doctor may run an EKG and you find out there’s nothing wrong with your heart. If you leave and your doctor bills your visit as a heart patient visit – which brings in additional money for that doctor – your medical records now register that you have a pre-existing heart condition even if that’s not the case.

This fake heart condition may affect your future ability to have health insurance or may cap your medical spending – and that’s just one example. Something like a faulty record can mean you are denied insurance in the future, billed at a higher rate or prescribed less effective medication in order to protect your “bad heart.”

Do I Need a Medicare Fraud Attorney?

If you suspect your provider of fraud, which costs taxpayers and the government millions of dollars in lost funds each year, funds that could stretch further to help more people, then you should contact a trusted attorney. An attorney can advise you on the next steps to take, how to gather evidence, and how to protect yourself from harm.

Whistleblowers are incredibly important for stopping fraud and bringing qui tam lawsuits to light. As a whistleblower, you may even be rewarded for your contribution. For example, a judge may reward you anywhere from 10-30% of the rescued money, so, if you are able to regain $200,000 of misspent taxpayer money, and you’re awarded 10%, that means you walk away with $20,000 for your good deed.

At Coxwell & Associates, PLLC, we have over 36 years of experience stopping providers from defrauding the government. We’re experts at seeking justice in qui tam and whistleblower lawsuits and have written a guide which includes everything you need to know about these lawsuits. Click on the button below and start your journey by downloading our guide.

Disclaimer: This blog is intended as general information purposes only, and is not a substitute for legal advice. Anyone with a legal problem should consult a lawyer immediately.