Health care fraud occurs when a medical provider intentionally submits false or misleading information for use in determining the amount of health care benefits payable. Upcoding and unbundling are forms of health care fraud. At times, innocent health care providers can be routinely accused of upcoding, unbundling, and other forms of health care fraud. If you’ve been accused of upcoding, unbundling, or some other form of health care fraud, you should contact an experienced health care fraud defense attorney immediately. In this article, we examine the practices of upcoding and unbundling.
What Is Upcoding?
Upcoding occurs when a health care provider submits codes for more expensive procedures or diagnoses than he or she actually performed or diagnosed. When health care providers upcode medical bills for Medicaid and Medicare patients, they cheat those programs of needed funds.
What Is Unbundling?
Medicare and Medicaid often provide lower reimbursement for groups of procedures that are commonly performed together, such as closures and incisions that are incidental to surgeries. Unbundling, also known as fragmentation, occurs when a health care provider illegally bills bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid. The Department of Justice prosecutes providers who engage in unbundling.
Upcoding, Unbundling, and EHR Software
Health care providers sometimes use electronic health records (“EHR”) software to facilitate upcoding and unbundling. With EHR software, medical providers can copy and paste notes from a patient’s last visit into each current treatment note. This can make it look like the provider has diagnosed and treated every condition on the list. In addition, providers sometimes restrict the menus on their EHR software to only display treatment codes and diagnoses with high reimbursement rates.
Common Defenses to Upcoding and Unbundling Accusations
As noted above, medical providers are sometimes mistakenly accused of health care fraud. Common defenses to upcoding and unbundling include:
- Unintentional mistakes,
- Performing the correct medical procedure instead of a less expensive one,
- Misinterpreting medical codes, and
- Clerical errors.
Although these defenses may seem simple, defending an upcoding or unbundling case can be extremely complicated. Therefore, if you’ve been accused of health care fraud, you need an experienced health care fraud defense attorney on your side.
Contact a Health Care Fraud Defense Attorney
If you’ve been accused of upcoding, unbundling, or some other form of health care fraud, you should contact an experienced health care fraud defense attorney immediately. At Griffin Durham Tanner Clarkson LLC, our health care fraud defense attorneys understand the ins and outs of health care fraud, and we are well prepared to defend you against all types of health care fraud accusations. In addition, our attorneys work nationwide, meaning that we can defend you against health care fraud charges regardless of where you reside in the United States. When you choose us to defend you, we will work tirelessly to protect your rights, your reputation, and your freedom. Please contact us today to schedule a free consultation.