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Florida Medical Billing Unbundling Fraud Attorney

Are you a healthcare provider witnessing fraudulent billing practices within your workplace? The unethical unbundling of medical services leads to inflated patient bills and unjust profits for healthcare providers.

Unbundling fraud causes unnecessary financial strain on innocent patients who don’t know they are being taken advantage of. Blowing the whistle on healthcare fraud is a complex process that can feel discouraging, especially when your career might be on the line.

At Yormak Employment & Disability Law, we understand the fears and questions that come with the decision to blow the whistle. But you don’t have to face this alone. We can help you understand your rights under the False Claims Act and build a strong case to help you achieve the best possible outcome. Contact Yormak Employment & Disability Law today for a free consultation.

Unbundling in Healthcare Billing Fraud

In the healthcare industry, unbundling refers to billing each step of a medical intervention as if it were a separate procedure. In essence, it’s a way of artificially inflating the cost of healthcare services by overcharging patients and defrauding government-funded healthcare programs like Medicare and Medicaid.

These programs often have different reimbursement rates for individual services than those in grouped procedures. In a legitimate billing scenario, a healthcare provider would bundle related services into one code, and the government program would reimburse at a rate that reflects the nature of the service.

However, when providers engage in unbundling fraud, they bill each component of a grouped procedure separately, resulting in billions wasted yearly.

The Difference between Unbundling and Upcoding Fraud

Unbundling and upcoding are types of billing healthcare fraud that frequently happen together.

  • Unbundling involves charging separately for services that should be billed together under one code.
  • Upcoding involves billing for a higher level of medical services than were provided or were medically necessary.

Examples of Unbundling Fraud

Unbundling fraud can take many forms. Below are a few common examples.

Medical Laboratory Tests: A patient has multiple blood tests done in a single lab visit. Typically, the lab bundles these tests into a single panel for billing purposes because they are processed together using the same sample. However, in an unbundling fraud scenario, each test is billed separately, resulting in a higher total charge.

Surgical Procedures: During surgery, multiple procedures often performed together and covered by a single billing code are billed individually. Each surgery step might be charged separately, like the incision, the actual repair, and the closure.

Radiology Services: If a patient has an MRI scan of multiple body areas that are usually covered under a single code, a fraudulent provider might bill each region’s scan as a separate procedure, inflating the overall cost.

Dental Procedures: A dentist performs a procedure that includes an examination, x-ray, and extraction. The standard practice is to bill for the extraction, which includes the exam and x-ray. However, the dentist commits unbundling fraud by charging for the x-ray and the exam separately from the extraction, even though they were part of the extraction.

Anesthesiology Services: An anesthesiologist provides pre-operative evaluation, anesthesia administration, and post-operative pain management, which should be billed under a single code.

Bundled Health Checkups: A patient goes in for a yearly health checkup, which includes a physical examination, blood pressure check, and a cholesterol test. The healthcare provider bills each of these components as a separate service.

In each case, the healthcare provider intentionally inflates the cost of care by breaking down services that should be billed together.

Examples of Upcoding Fraud

Upcoding fraud can take many forms. Below are a few common examples.

Emergency Room Services: A patient visits the emergency room with symptoms of a headache and dizziness. After evaluation, the patient is diagnosed with a minor headache. In an upcoding scenario, the hospital bills the insurance for a migraine with severe complications, which is a higher-cost diagnosis, despite the patient only receiving fairly basic primary care.

Physical Therapy Treatment: A patient receives a standard physical therapy session for a sprained ankle, typically involving simple exercises and ice therapy. However, the clinic submits a claim using the billing code for an advanced therapeutic procedure. This implies that the patient received more complex treatment than was provided.

Diagnostic Imaging: A patient undergoes a standard X-ray due to a minor injury. In this case of upcoding, the radiology center bills the insurance for a comprehensive CT scan, which is more expensive and suggests a higher level of diagnostic service that was not performed.

The False Claims Act & Whistleblower Rewards

The False Claims Act (FCA) is a federal law that imposes liability on individuals and companies who defraud governmental programs.

Under the FCA, private citizens can sue on behalf of the government and share in any recovery. Whistleblowers who report healthcare fraud are entitled to protection from retaliation and may receive a portion of the recovered damages.

Whistleblowers can receive between 15% and 30% of the total recovery from the lawsuit when the government intervenes. These rewards might run into hundreds of thousands or even millions of dollars recovered.

Whistleblower Claims

The criteria for government intervention in cases brought under the FCA, particularly those involving healthcare fraud such as unbundling or upcoding, typically include several factors.

Strength of Evidence: The government assesses the quality of evidence presented. Strong evidence that demonstrates fraudulent activity is crucial. This might include detailed billing records, internal correspondence, or firsthand witness testimony.

Extent of Fraud: The scope and impact of the alleged fraud are considered. If the fraud has led to substantial financial losses for government programs or is systemic within a company, it is more likely that the government will intervene.

Potential Recovery: Economic considerations play a role. The government might be more inclined to intervene if the possible recovery amount is significant. This is partly because the FCA allows the government to recover treble damages, meaning three times the amount of the proven fraud.

Public Interest:  If the fraud has the potential to harm public health, lead to patient safety issues, or undermine the integrity of government healthcare programs like Medicare and Medicaid, the government is more likely to intervene.

Hiring an experienced attorney can play a crucial role in determining if you have a potential whistleblower case in your hands. They can help you identify violations of the False Claims Act and help you prepare a strong claim.

Contact Us for a Free Consultation

Whistleblowing bundling fraud requires an attorney with extensive experience in healthcare fraud—and that’s where Yormak Employment & Disability Law comes in.

We understand the ins and outs of healthcare billing fraud and have a track record of successfully representing whistleblowers. We can help you understand your rights, build a case, and navigate the legal process for the best possible outcome. Contact us today for a free consultation.

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