by | last updated on January 21, 2016
Current Procedural Terminology (CPT) codes are used in an assortment of paperwork pertaining to healthcare. They help determine costs for particular types of treatment or care, diagnoses, services provided and more. Confusion regarding CPT codes (which may consist of five numbers or four numbers and a letter at the end) can lead to mistakes that could be mistaken as healthcare fraud. If this is the case, healthcare providers could face charges.

Fraud Involving CPT Codes

One type of fraud involving CPT codes is called upcoding. When a medical procedure or service has been performed, the healthcare provider will assign a code to it. This determines how much the provider is going to be paid, so it’s important that the code matches the procedure or services performed.

A bill is then sent to the patient, his/her insurance company, Medicare or Medicaid. The healthcare provider will receive payment based on the CPT code. If the wrong code(s) is used in order to receive more money than should be paid, this may be medical upcoding fraud. In other words, the healthcare provider fraudulently claims a service was performed that generates more reimbursement from insurance or from Medicare or Medicaid.

Consequences of Upcoding

If convicted of Medicare fraud charges, healthcare professionals could face serious penalties. Fines might be imposed, the doctor may lose his or her license, and some could even face jail time.

Not only is this practice unethical and illegal, but it also can result in negative consequences for the patient. One way is that his/her medical records could indicate a health problem that doesn’t really exist. This may result in the wrong type of care later on.

In the event medical upcoding fraud or other healthcare billing fraud is suspected, an attorney can help healthcare providers or facilities if they are audited. During the audit, providers should prove the upcoding was unintentional (using the wrong code, mixing up numbers, etc.) or that the services claimed actually were performed.

Get Legal Help from Robert David Malove

Healthcare providers who are accused of upcoding or any other Medicare fraud related matter should contact an attorney right away. Call the Law Offices of Robert David Malove at (888) 744-8225 to set up a consultation to review the details of your case and possible defenses for these or other charges.