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Florida Upcoding Lawyer

Qualifying individuals are entitled to numerous benefits through Medicare, including costs of hospitalization, expenses for medical treatment, and prescription medications. To recover the expenses related to providing these services, health care providers submit documentation to support their claim for payment. However, some practitioners may include false or misleading information when presenting claims. In fact, the Centers for Medicaid & Medicare Services (CMS) reports an improper payment rate of around 7.5 percent, which amounts to Medicare fraud and cheats taxpayers out of $30 billion every year. Upcoding is one tactic used by fraudsters to effect this scheme.

The Federal False Claims Act (FCA) allows whistleblowers to recover compensation when they bring Medicare fraud to the attention of officials. If you have information related to upcoding or other deceptive billing practices, please contact Guttman, Freidin & Celler to set up a no-cost case review. A Florida Medicare fraud lawyer can explain the specifics, but an overview of upcoding may help you identify misconduct.

Upcoding as Medicare Fraud

The definition of fraud is using deception to gain a financial advantage or other item of value; Medicare fraud is a specific type of misconduct in which a health care provider provides false information in connection with the process of reimbursement through CMS. Upcoding is one tactic that relies on the system of CPT codes, which are used to identify medical services delivered by a health care professional.

To set the stage for a fraudulent upcoding scheme, the physician might report symptoms or diagnose a medical condition that does not apply to the patient. Then, the provider “upcodes” by submitting CPT codes after performing services that are not medically necessary. Not only does this practice defraud CMS, but it can also result in serious harm to the patient.

Seeking Remedies as a Whistleblower

The FCA encourages individuals to come forward and blow the whistle when they have information regarding schemes to defraud the government. This statute does apply to upcoding scams, and it creates a cause of action known as a qui tam lawsuit. A Medicare fraud lawyer will advise you on the details, but note the following about these cases:

  • As a qui tam plaintiff, you may qualify to sue a health care provider for upcoding or other unlawful billing practices.
  • After filing your case, the government has the opportunity to intervene, i.e., take over the case on your behalf. If the government does not intervene, you pursue your FCA remedies.
  • If the facts prove illegal upcoding, the defendant is liable for three times the amount misappropriated from CMS.
  • You might receive 15 to 25 percent of the amount recovered if officials intervene, and 25 to 30 percent if they do not.

Get Legal Help from a South Florida Medicare Fraud Attorney

If you have concerns about upcoding by a health care provider or medical practice, please contact Guttman, Freidin & Celler right away. You can call 800.654.8281 or use our contact form to schedule a free consultation at our offices in Miami, FL. After we review your circumstances, we can advise you on the next steps through a Medicare fraud whistleblower case.

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