Colorado Medical Coding Fraud Lawyer

Do you have information about a doctor’s office or other healthcare facility involved in fraudulent medical coding or billing? If so, you could be entitled to compensation through a qui tam whistleblower lawsuit. Under a federal law known as the False Claims Act, you have the right to report suspected billing fraud without fear of retaliation by your employer.

At The Wilhite Law Firm, our Colorado medical coding fraud attorneys can protect your rights and help you develop a strong case against fraudulent and abusive medical facilities.

What Is Medical Coding Fraud?

Many medical facilities work with government insurance providers like Medicaid, Medicare, and TRICARE to provide healthcare services to military service members and people who are retired, disabled, or living on low incomes.

When Medicaid, Medicare, and TRICARE recipients receive health care services from these facilities, the providers submit claims to government insurance programs for reimbursement. Providers include special codes in these claims to designate which services were provided and how much money they should receive from government insurers in return.

Medical coding fraud occurs when medical providers knowingly submit claims with false information about services they provided to make extra money. This could include submitting incorrect:

Billing codes
Diagnostic codes
Service units
Service dates
Provider information

The goal of submitting this misinformation is to inflate reimbursement amounts artificially.

One of the most common types of medical coding fraud involves upcoding, which refers to healthcare providers submitting billing codes for services with higher reimbursement values than the services that were actually provided. When healthcare provider uses upcoding to obtain more money than they deserve, they commit fraud, and drain funds from government healthcare programs intended to help people in need.

How Does Upcoding Work?

When medical providers seek reimbursement from either private insurance companies or government insurance programs, they use numbered codes to designate the specific types of services rendered. Some common types of codes include Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes.

Thousands of different codes reflect the vast number of medical procedures, diagnostic results, and treatment types eligible for reimbursement from government insurance programs. Medicaid, Medicare, TRICARE, and other federal healthcare programs assign specific reimbursement amounts to each code. The more complex and intensive a particular diagnosis, procedure, or treatment, the more money providers can claim for it.

As a result, medical facilities know precisely how much money they’re getting for every service they provide, making fraudulent upcoding relatively simple. All providers need to do to defraud the federal government is include CPT or HCPCS codes for more valuable services in their claims and pocket the extra reimbursement money.

The Costs of Upcoding Fraud

Medical corporations overcharging faceless government agencies may seem like a minor issue in the grand scheme of things. However, medical coding fraud is a crime against society as a whole. Government health insurance programs are funded by taxpayer dollars, which means every fraudulent claim steals money away from taxpayers and leaves people in need with fewer resources.

According to the American Medical Association’s (AMA’s) Journal of Ethics, upcoding and other types of medical billing fraud cost taxpayers more than $100 billion every year. In just one recent year, the Centers for Medicare and Medicaid Services (CMS) paid roughly $1.1 trillion to provide healthcare services to 145 million Americans. An estimated $95 billion of the total amount spent that year was paid for abusive or fraudulent claims.

The Federal Bureau of Investigation (FBI) reportedly estimates that 3 to 10 percent of the country’s total healthcare expenditure is related to fraudulent billing for services. This unethical form of theft directly results in inefficient healthcare systems, higher medical costs, and unconscionable waste.

Medical worker computing miscellaneous fees and others.

Examples of Medical Coding Fraud

Some common types of medical coding fraud include:

Upcoding – Upcoding occurs when healthcare providers bill government insurers for more valuable services than those actually needed. That can include billing for services that were never performed or medically necessary.
Unbundling – Unbundling occurs when providers separate services that are typically bundled together as one code into individual codes to charge more money for each separate service.
Split billing – Split billing occurs when providers bill the government separately for a series of services provided during one visit as though the services were provided over the course of multiple visits.
“Kitchen sink” coding – Kitchen sink coding occurs when physicians bill government insurers for multiple unconfirmed diagnoses, although only one or two diagnoses have been confirmed.
Unsupervised billing – Unsupervised billing occurs when medical facilities bill government insurers for services performed by supervised and licensed physicians even though unsupervised or unlicensed medical providers actually performed those services.

How Do You Report Upcoding, Unbundling, and Other Types of Healthcare Fraud in Colorado?

Medical coding fraud is challenging to identify because of the highly specialized nature of healthcare terminology, services, and billing. As a result, most whistleblowers who report medical fraud are nurses, medical assistants, co workers, administrators, and other healthcare employees who are familiar with the system and can recognize when something isn’t right.

If you suspect upcoding, unbundling, or another type of healthcare fraud has occurred, you have the right to file a qui tam lawsuit under the False Claims Act (FCA). The FCA also referred to as the Lincoln Law, offers whistleblowers a safe and reliable way to report fraudulent and abusive behavior while prohibiting professional retaliation. That means you cannot be suspended, fired, demoted, harassed, or discriminated against at work in response to your whistleblower efforts.

You can file a qui tam lawsuit in response to suspected medical coding fraud with the help of a knowledgeable attorney. When you file your case, the government will investigate your suspicions to determine whether fraud occurred. If you recover money on behalf of the government through your lawsuit, you may be entitled to between 15 and 30 percent of the recovered funds as a reward.

Our Colorado Qui Tam Attorneys Are Experienced in Handling Coding Fraud Whistleblower Cases

You can do your part to hold unethical medical providers and facilities accountable by reporting medical coding fraud under the False Claims Act. Contact the knowledgeable qui tam attorneys of The Wilhite Law Firm in Colorado today to discuss the details of your situation in a free and completely confidential case review.