How to report upcoding fraud against Medicare or Medicaid and receive a whistleblower reward

Reporting upcoding fraud

This article shows you how to get a reward for reporting fraud against Medicare or Medicaid by upcoding its diagnostic codes.

Many hospitals, doctors and healthcare provides cheat Medicare by “upcoding” their bills. Medicare and Medicaid typically reimburse hospitals, doctors and healthcare providers using a prospective payment system (PPS). Every illness or medical procedure is assigned a diagnostic code, which is referred to as a current procedural terminology code (CPT code). The CPT code represents the amount of money hospitals, doctors and healthcare providers will be reimbursed for the medical services they provide to Medicare or Medicaid recipients.

For instance, if a Medicare provider uses the CPT diagnosis code for bronchitis, they get paid a set amount of money regardless of how much the treatment cost. However, if they use the CPT diagnosis code for pneumonia, they get paid a higher PPS amount because it generally costs more to treat that condition. Under Medicare upcoding fraud, a hospital or healthcare provider creates a scheme where they decide to use a higher paying CPT code to cheat and collect more money.

Approximately ten percent of Medicare or Medicaid spending by the government is lost to fraud, such as the common scheme of upcoding. When others cheat or defraud Medicare by upcoding it costs all of us in increased healthcare costs and taxes.

Fortunately, you’re invited to report upcoding fraud against Medicare and Medicaid, which not only helps stop the upcoding fraud but also pays significant monetary whistleblower rewards. To get a reward for reporting Medicare upcoding fraud, you must follow the correct rules and procedures for reporting a hospital or healthcare provider that is upcoding . It is also helps ensure that Medicare opens an investigation.

This article outlines the basics for how to report upcoding fraud and how to apply for a whistleblower reward for reporting upcoding fraud against Medicare or Medicaid.

Medicare upcoding fraud examples

As stated above, Medicare pays or reimburses hospitals, doctors and healthcare providers for treating Medicare patients based upon what prospective payment system code (PPS code) based upon the current procedural terminology code (CPT code) they report to Medicare. It’s upcoding fraud for a hospital, doctor or healthcare provider to use a different CPT code than the actual diagnosis. Sometimes hospitals, doctors and healthcare providers purposefully cheat on a large scale. For instance some upcoding schemes consist of having the doctor, coder or billing department upcode or bill at a higher level of service than provided. Upcoding schemes can be as blatant. Some are very specific, such as billing every Medicare patient that has a cold with the CPT diagnostic code for pneumonia. Other upcoding fraud schemes are more general, such as telling employees to bill to the next higher code for all Medicare recipients.

Tips for reporting upcoding fraud

Here are some tips for how to report upcoding fraud.

First, you can’t simply call a hotline to report upcoding fraud. The only way how to get a reward for reporting upcoding fraud by a hospital, doctor or healthcare provider is using an attorney (on a contingency basis consisting of a portion of any whistleblower reward) to file qui tam suit under the False Claims Act. Your attorney must follow the exact process in the reward statute to get a reward for reporting upcoding fraud. Therefore, it is key that you select an attorney experienced with handling reward applications for upcoding fraud and Medicare fraud cases.

In addition, you need to report in detail how the hospital, doctor or healthcare provider is engaged in the upcoding scheme to defraud Medicare. The government needs your help in uncovering upcoding fraud, but because most whistleblower reward applications lack specific proof, the government turns away 75% of the claims. Again, that’s why selecting an experienced attorney that has handled upcoding fraud cases is important.

How much reward for reporting upcoding fraud?

The size of a whistleblower reward is calculated based on the size of the Medicare upcoding fraud case. The reward is in the range of 15 to 25 percent of the amount of the upcoding that Medicare, through your attorney’s help, recovers back from the hospital, doctor or healthcare provide that is cheating and being overpaid by upcoding.

How to report upcoding fraud

This website (and the books authored by Mr. Hesch) walk you step-by-step through the entire process of reporting upcoding fraud against Medicare and shows you how to report upcoding fraud to obtain a whistleblower reward.

Because there are certain risks for reporting fraud against the government, including Mediare or Medicaid upcoding fraud, you should have a candid talk to your attorney before you blow the whistle and report upcoding fraud.

Mr. Hesch has considerable experience with investigating upcoding fraud against the federal government while working at the Civil Fraud Section of the U.S. Department of Justice in Washington, D.C. He is ready to review your information and show you whether and how to report fraud against Medicare by upcoding fraud schemes.

The link below “Do I have a case” shows you how to ask Mr. Hesch to review your potential Medicare upcoding fraud case and how to get a reward for reporting upcoding schemes.

The link below “Report Fraud” has more information regarding how to get a reward for reporting upcoding fraud against Medicare or Medicaid.