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Upcoding & Unbundling – FAQs

Upcoding and unbundling are two methods of healthcare billing fraud that involve applying improper codes for different medical diagnoses and procedures. Healthcare providers that treat Medicare and Medicaid patients submit claims for reimbursement from the government using billing codes that identify what the patient received. When these healthcare providers knowingly improperly code what medical services were provided in order to obtain unwarranted funds from the government, they are committing coding fraud.

Each year, both the government and taxpayers whose money fund programs like Medicare and Medicaid lose billions of dollars to the healthcare fraud practices of upcoding and unbundling. If you have proof of coding fraud, contact the Medicare fraud qui tam lawyers of Tycko & Zavareei LLP today for a free legal consultation.

What Is Upcoding?

When a healthcare provider bills for a more serious or expensive procedure or medical diagnosis than what was actually performed or diagnosed it is referred to as upcoding. The billing codes that healthcare professionals use to bill Medicare or Medicaid for patients correspond to a specific procedure or diagnosis, and the government uses these codes to determine the amount of money to reimburse.

What Is Unbundling?

Unbundling, sometimes called fragmentation, refers to the practice of illegally billing procedures that are bundled together separately. Because Medicaid and Medicare bundles procedures that are commonly performed at the same time, separating these bundled procedures and billing for them separately results in illegally increased profits for providers.

Why Is Upcoding & Unbundling Unethical?

Besides being illegal, upcoding and unbundling are unethical for several reasons. When healthcare payers like Medicaid and Medicare experience increasing costs due to healthcare professionals illegally upcoding and unbundling billing codes, this increase is reflected back on to citizens in the form of increased taxes, higher healthcare costs, or a lower standard of care.

Many patients do not understand billing codes, so it can be difficult to spot healthcare billing fraud like upcoding and unbundling from the outside. Employees of healthcare providers with proof of healthcare fraud who come forward as qui tam relators and assist the government in recovering defrauded funds are one of the most important ways to stop healthcare fraud.

How to Spot Medical Billing Fraud

Medical billing fraud and abuse can take years to detect. The first line of defense against healthcare providers who illegally bill government health care programs are the people who work there and notice it taking place. If you have proof of healthcare billing fraud and your qui tam lawsuit is successful, you may be awarded a percentage of the defrauded funds that are recovered.

Here are common examples of medical billing fraud:

  • Billing for services not rendered that the patient never received
  • Billing twice for the same service
  • Billing for a more complex and costly procedure than what the patient actually received
  • Upcoding a singular procedure so it is billed multiple times: Also referred to as double billing, this can include attempting to obtain payment for a patient’s single procedure from a private insurer, the patient, or public health programs at the same time.

How to Report Medical Billing Fraud

If you have proof of medical billing fraud, you may be qualified to file a lawsuit against the healthcare provider. If your actions as a whistleblower lead to the government being able to recoup defrauded funds, you may be entitled to a percentage of the total amount that is recovered.

What is a Qui Tam Relator?

Under the False Claims Act, the qui tam provision gives individuals with knowledge of fraud against the government the ability to sue the entity engaging in fraudulent activity on behalf of the government. This type of lawsuit is called a qui tam lawsuit and the whistleblower who brings the lawsuit is otherwise known as the qui tam relator. Most often, the qui tam relator is an employee who is able to gather inside information regarding the alleged medical billing fraud.

Medical Billing Fraud & Whistleblower Rewards

Whistleblowers whose tips lead to successfully recovered defrauded funds are awarded for their bravery with a percentage of the total that is recovered. The percentage whistleblowers may receive ranges between 15 and 30 percent of the total that is recouped, with whistleblowers often receiving significant financial compensation.

Additionally, whistleblowers are protected from retaliation by their employer under the False Claims Act. Employees who become whistleblowers must not be suspended, terminated, demoted, threatened, harassed, or discriminated against in any way for their actions as a whistleblower. If the qui tam relator does experience retaliation, they have the right to bring a lawsuit against their employer.

Hiring a Healthcare Fraud Lawyer: What to Look For

Reporting medical billing fraud can be intimidating, but having the right healthcare fraud attorney on your side can take pressure off of you as you navigate the qui tam legal process. Additionally, an experienced qui tam law firm like Tycko & Zavareei LLP can help maximize your chance of the lawsuit being successful. When hiring a healthcare fraud lawyer, consider the following:

1. Proven success and positive testimonials

A qualified whistleblower law firm will have a proven track record of success representing whistleblowers in cases where the government successfully recovers defrauded funds. At Tycko & Zavareei LLP, our attorneys have worked on many cases that have resulted in multimillion-dollar settlements, including a pharmaceutical kickback case that settled for $350 million and a Medicare fraud case that settled for $7.5 million.

2. Extensive experience with qui tam medical fraud

Our qui tam healthcare fraud attorneys have experience handling a vast number of healthcare fraud cases involving government-funded programs, including Medicaid, Medicare, Veterans benefits programs, and TRICARE. Our qui tam lawyers have represented healthcare fraud whistleblowers across the country who have assisted the government in recovering billions of defrauded taxpayer dollars.

3. Ability to protect your interests

With Tycko & Zavareei LLP, you will be protected from retaliation to the fullest extent of the law. Whistleblower claims are kept sealed until the government intervenes or the whistleblower pursues the case on their own and the defendant is served. Cases are often sealed for a full year before a decision is made, preserving your anonymity. If the whistleblower complaint is served and the defendant seeks to retaliate against you for being a whistleblower, the qui tam lawyers of Tycko & Zavareei LLP can help you understand and pursue your options for legal recourse.

What is the Whistleblower Protection Act?

Under the Whistleblower Protection Act, federal employees are protected from retaliation for whistleblower actions, too. This law gives federal employees protection for exposing unlawful behavior, including the violation of rules, regulations, or laws; abuse of authority; waste of funds; gross mismanagement; and danger to public health or safety.

Contact Us

If you have proof of healthcare billing fraud, you may be entitled to a financial reward. Contact the medical billing fraud whistleblower lawyers of Tycko & Zavareei LLP today for a free legal consultation.

How can we help you?

Confidential Case Evaluation

Our experienced qui tam attorneys are available for a confidential, no-cost, no-commitment, initial evaluation of your case. Call us now at (202) 973-0900, or begin the process by completing our Confidential Case Evaluation Form.
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