Up-coding Medicare/Medicaid claims is fraud, and a whistleblower can be rewarded up to 30% of the Government’s recovery

Up-coding Medicare/Medicaid claims is fraud, and a whistleblower can be rewarded up to 30% of the Government’s recovery for reporting fraud through a False Claims Act qui tam lawsuit. Up-coding is the practice of using (or failing to use) the proper medical service codes and modifiers when billing.

Up-Coding Examples

Examples include, billing for mid-level practitioners (Physician Assistants, Nurse Practitioners, etc.) at the physician rates by failing to use the proper modifier, which causes reimbursement at a higher rate. Another example is using a code for more complex procedure or device than what was provided in order increase profits. Up-coding is common in medical billing. However, when up-coding is sent to Government funded healthcare programs like Medicare and Medicaid, it is subject to the FCA and may even be criminal. 

False Claims Act for Up-Coding

Whistleblowers who expose up-coding schemes through the filing of a False Claims Act qui tam lawsuit may be compensated by receiving a percentage of the Government’s recoveries.