Current Procedural Terminology (CPT) codes help determine billing charges, depending on the services provided. Upcoding is when a healthcare provider logs a code that gives them a higher payout than the code for the actual service provided. This can be dangerous, as it affects the patient’s medical records, which might influence future treatment in some cases. These are serious charges for a healthcare provider to face and hiring an experienced healthcare fraud lawyer can make all the difference in your case.
Although it is sometimes done fraudulently, many times it is the result of a clerical mistake or simple misunderstanding. Healthcare providers who find themselves facing these charges should begin taking steps to defend themselves and prove that upcoding was not present or that any instances of upcoding were not fraudulent.
What is Upcoding?
Medical facilities are expected to submit accurate and truthful records of the treatments, procedures and services they provide in caring for their patients. Each individual procedure has a specific code used to identify it, and the healthcare facility will use these codes to bill insurance companies or government programs for services they’ve provided to policyholders.
Upcoding is when a doctor, health care facility, or medical supply/service company renders a service to a patient and then submits a bill using a code that corresponds to a higher cost service. Typically the services are similar in nature but have differences in charges, such as a normal consultation versus an extended consultation.
Detecting Cases of Upcoding Fraud
Through audits and whistleblowers, upcoding may be detected and those accused of committing these fraudulent acts could face healthcare fraud charges. Audits may be conducted at random in many cases, so it’s important to always keep accurate records to answer any inconsistencies or inquiries regarding billing of services. A Fort Lauderdale healthcare fraud lawyer may utilize these records when defending against charges of fraudulent billing.
A whistleblower is an informant with knowledge of a healthcare provider’s potentially fraudulent billing practices. These informants are often compensated for their information if a case of fraud is found and results in a recovery. The whistleblower may receive a percentage of the recovery. If an individual brings forth allegations of fraudulent practices, consult a Fort Lauderdale healthcare fraud lawyer to begin addressing the accusations.
Defenses to Upcoding Charges
The allegation of intentionally and fraudulently overcharging an insurance company—whether private insurance, Medicare or Medicaid—is not an issue to be taken lightly. On the surface it can easily appear to be a case of fraud – doctors and other healthcare providers just trying to make some extra money.
But the system for coding medical procedures can be quite complex, resulting in unintentional mistakes. Determining which code(s) to use can also be very time-consuming, resulting in a doctor inadvertently choosing the wrong one. Or it may be that in trying to decipher which code to use, a doctor misinterprets the factors necessary to justify using a particular code.
If investigated for fraud, a healthcare provider may need to prove that the billing codes assigned were justified. This may require providing documentation to demonstrate that a particular service was in fact provided to the patient.
Of course, some cases of upcoding are simple clerical errors. The code may have been input incorrectly or there may be miscommunication between office staff regarding the service provided to a particular patient. According to ConsumerReports.org, “Medical Billing Advocates of America, a national association that checks bills for consumers, says 8 out of 10 hospital bills its members scrutinize contain errors.”
Seeking Help from an Experienced Fort Lauderdale Helahtcare Fraud Lawyer When Charged with Upcoding
If there is a consistent pattern of billing errors, this can definitely lead to the appearance of fraudulence. Therefore, it’s important to seek legal advice upon any allegation of fraudulent billing. By addressing the matter early, instances of coding errors may be spotted so the healthcare provider and his or her attorney can work to rectify the situation.
Even if upcoding charges have already been filed, an experienced Fort Lauderdale healthcare fraud lawyer can help. To learn more about defending one’s rights, contact our Florida firm online or give us a call at 954.861.0384 today!
