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Every office visit, test, procedure, or anything else that gets billed by a medical provider has a code attached to it, known as a Current Procedural Terminology code, or CPT code for short. When doctors bill the insurers – either private insurers or the government (Medicare) – for services provided, they bill by the CPT code attached to every service.

Upcoding occurs when a doctor bills for a more expensive service than the one that was provided. In a busy hospital, clinic or doctor’s office, the provider might not even know their services are being upcoded to defraud the insurer. Upcoding happens so often that the Centers for Medicare & Medicaid Services (CMS) estimates that about seven and a half percent of its payments are based on improper code reporting. Given the size of Medicare, this significant percentage amounts to $30 billion lost to fraud every year. The cost of this fraud is ultimately borne by the taxpayers.

If you work in a hospital or doctor’s office and become aware that upcoding is going on to get fraudulent overpayments from the government, you can do something about it, and Stacey Evans Law can help. We can help you file a whistleblower lawsuit against the fraudulent health care provider and prove your case in court. You do your part to help the government recover the monies it has overpaid, and they reward you by cutting you in on a substantial portion of the proceeds, as much as 30%. Learn more below about upcoding Medicare fraud, and call the health care fraud whistleblower attorneys at Stacey Evans Law if you suspect upcoding at your workplace in Atlanta or Georgia statewide.

How Do You Detect Upcoding?

In some cases, doctors will misdiagnose a patient with a condition they don’t really have and then perform unnecessary medical services that the patient doesn’t really need so they can bill Medicare for the service. Upcoding can be harder to spot because the patient might legitimately need or get the service billed for, but it is billed improperly by using the wrong. Common examples of upcoding include:

  • A procedure was performed by a nurse or physician’s assistant but billed as though it was done by the doctor, at a higher rate of pay
  • Sedation is billed as anesthesia
  • An x-ray is billed as though multiple views were taken when only one x-ray was done
  • The doctor conducts a follow-up visit for a current patient but codes the visit as a new patient, generating higher Evaluation & Management (E&M) rates for reimbursement
  • The provider uses the E&M Modifier 25 code to gain an additional payment for a separate service on the same day, but that service is insignificant, inseparable from the other service, or generally considered part and parcel with the service

How to Blow the Whistle on Upcoding

If you notice upcoding going on at the hospital or medical office where you work and believe the fraud is significant or ongoing, you can put a stop to it by blowing the whistle on the fraudulent practice. Blowing the whistle means filing what is known as a qui tam lawsuit under the False Claims Act. As a qui tam plaintiff, you are bringing suit on behalf of the federal government. If the government decides to intervene in your case, they will take over the lawsuit for you, but you’ll still recover 15 to 25% of any amount of money the government recovers, which is up to triple the amount the provider defrauded the government out of, plus other potential penalties. If they don’t intervene, you can continue the lawsuit yourself and this time you’ll be paid 25 to 30% of any monies you collect on the government’s behalf. In either case, as a whistleblower you are protected by law from termination or other negative employment based on your participation.

The experienced health care fraud attorneys at Stacey Evans Law will handle every aspect of your case. We’ll file the claim and sue to recover a money judgment from the health care provider, assuming the government doesn’t intervene. We’ll also make sure you are not mistreated at work for blowing the whistle or file a separate retaliation claim if you are.

Representing Whistleblowers in Atlanta and Georgia Statewide in Cases of Upcoding and other Medicare Health Care Fraud

If you’ve noticed a pattern of upcoding at a hospital, medical clinic or doctor’s office in Atlanta or throughout Georgia statewide, call Stacey Evans Law at 404-850-6750 to speak with an attorney.

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