Feds Call for Better Oversight on Medicare Billing Practices — Again

The closer we get to the next U.S. presidential election, the more likely it is that Americans will, once again, be lamenting the future of Medicare. Will there be enough money in the coffers when the people who are paying into it need it (in 10, 20 or 30 years?)

By all accounts, if the current Medicare billing abuse that is widespread among health insurance companies and others continues, there will be very little, if any money, left – sooner rather than later. The answer seems simple: officials must find a way to get to the bottom of purposeful billing errors and over-payments to some Medicare plans, including Medicare Advantage. These mistakes are costing American taxpayers billions of dollars every year.

The most frustrating part of this story, for Joe Taxpayer, is that doctors and healthcare facilities are exaggerating how sick some people are and, subsequently, do something called “upcoding.” Upcoding is the practice of billing the insurance, in this case, Medicare, for tests and treatments that are far more costly than are required.

“Upcoding is a theft and is fraudulent on its face,” maintained experienced qui tam attorney Ross Begelman of Begelman & Orlow, P. C.. “When you claim and charge the government for services not provided, or for care which would not otherwise be paid for if not for the upcode, medical providers are stealing from the government.”

Begelman added upcoding can happen in two ways, but regardless upcoding is actionable under the False Claims Act. “Some upcoding frauds involve an upcode to the service actually provided. Other types involve upcoding the patient’s condition so a patient can have access to a service that would otherwise not be reimbursable.”

The latter point might seem like compassionate care for patients. In some cases, it may be. However, “most providers who upcode in this way do so not out of the goodness of their hearts but rather to increase their payments from the government that they would otherwise not receive,” Begelman said.

Patients generally don’t notice upcoding for two reasons:

  1. They aren’t familiar with any of the coding procedures so they can’t be expected to know what’s appropriate; and
  2. Generally speaking, a patient (in the case of Medicare, a senior citizen) may have a variety of ailments and doesn’t really care how much the doctor bills out for. As long as their copay is accepted at checkout, and they walk away with treatment, they are happy.

Therefore, it’s incumbent on medical office workers to keep their eyes open for this type of fraud in healthcare facilities. Also, better system-wide oversight is necessary and long overdue.

To that end, a researcher at the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality suggested that audit standards can and should be tightened to make it easier to find and stop offenders who habitually overbill health plans like Medicare.

“Upcoding is exactly the type of fraud that the Congress enacted the False Claims Act to prevent.  Our practice has filed many such cases,” said Begelman.

If you are aware of wrongdoing against the U.S. government, with relation to Medicare or something else, you may be entitled to a cash reward for blowing the whistle on the people committing fraud. Contact Begelman & Orlow, trusted and skilled qui tam attorneys, who can guide you through the whistleblowing process every step of the way.

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