Reporting unbundling fraud
This article addresses how to get a whistleblower reward for reporting fraud against Medicare or Medicaid by unbundling its Medical services or procedures.
One way doctors, hospitals and healthcare provides cheat Medicare is by “unbundling” their Medicare bills. Medicare and Medicaid reimburses doctors, hospitals and healthcare providers using a prospective payment system (PPS). All illnesses or medical procedures are assigned a diagnostic code, which is called a current procedural terminology code (CPT code). Every CPT code is assigned a dollar amount that Medicare reimburses to doctors, hospitals and healthcare providers for services they provide to Medicare patients.
For example a knee replacement might be reimbursed by Medicare in the amount of $11,000 per procedure, regardless of how much it costs. But, if the hospital were to unbundle all of the individual procedures and bill them separately, it might be reimbursed double or triple that amount. It is considered Medicare unbundling fraud, when a doctor, hospital or healthcare provider unbundles a single procedure that has a CPT code and bills them as if they were separate incidents.
Nearly 10% of Medicare spending by the federal and state governments is lost to Medicare fraud, including the common scheme of unbundling. When Medicare providers cheat or defraud Medicare by unbundling it costs we each suffer increased healthcare costs and higher taxes.
The good news is that the government wants you to report unbundling fraud against Medicare and Medicaid, and offers large whistleblower rewards. To receive a reward for reporting Medicare unbundling fraud, you must follow exact procedures for reporting a doctor, hospital or other healthcare provider that is unbundling. It is also the best way to get Medicare to open an investigation.
This article addresses how to report unbundling fraud and how to get a whistleblower reward for reporting unbundling fraud against Medicare.
Medicare unbundling fraud examples
As stated above, Medicare reimburses doctors, hospitals and other healthcare providers for treating Medicare patients based upon the prospective payment system code (PPS code) system using the current procedural terminology code (CPT code). However, when an entire procedure is listed in the CPT code book, a Medicare provider may not unbundle it to bill for each component separately.
As in the example of a doctor performing a knee replacement, the CPT code pays the doctor $11,000. Sometimes the cost for that procedure is $10,000 and other times it may be $12,000, but nationwide the average is $11,000 and that is how much each doctor receives for that service or medical procedure. However, some doctors, hospitals and healthcare professionals are not satisfied with receiving $11,000. They know that they can get three times that amount under the PPS system if they pretend that they did many separate services. In other words, they bill separately for each step along the way, including the office visit, the w-ray, the diagnosis, the operating room, followup visits, etc. When all of these CPT codes are added up, it is often double or triple the amount of the CPT code for the knee replacement.
Look at it this way. If you were to buy a car that has a blue book of $11,000, you would expect to pay about $11,000. But what if the car dealer charged you an individual price for every component of the car as if you went to the local auto supply store to buy them individually. It would easily cost you triple the blue book value. No one would think that is fair or would pay three times the blue book value of the car. But that is exactly what doctors, hospitals and other healthcare providers are doing when they unbundle or separate out the costs from a single procedure when they bill Medicare. That is unbundling fraud and it’s wrong.
Those that are willing to cheat and commit Medicare unbundling fraud don’t stop with one procedure, but do this for many procedures and overbill Medicare by millions of dollars a year. That’s why Medicare is asking for your help to fight unbundling fraud and willing to give you a whistleblower reward.
Tips for reporting unbundling fraud
Here are just a few important tips for how to report unbundling fraud.
First, you don’t call a hotline to report unbundling fraud and expect a reward. In fact, the reward statute prohibits paying rewards based on tips. Instead, the rules mandate that the only way how to get a reward for reporting unbundling fraud is using an attorney (on a contingency basis that is a portion of any whistleblower reward) to file a qui tam lawsuit under the False Claims Act. Your lawyer must strictly follow the exact procedures to get a reward for reporting unbundling fraud. Therefore, you should select a lawyer with experience handling reward applications for unbundling fraud and Medicare fraud cases.
Next, you must report the unbundling scheme in detail describing how the doctors, hospitals and healthcare providers went about unbundling in order to defraud Medicare. If you don’t report unbundling fraud correctly, you will be among the 75% of whistleblower applications that are rejected. That is why it is key that you select a lawyer with experience with unbundling fraud cases.
How much reward for reporting unbundling fraud
The size of a whistleblower reward is determined by the amount Medicare recovers in your unbundling fraud case. The reward is 15% to 25% of what Medicare gets back from the Medicare provider that is cheating or overcharging through unbundling.
How to report unbundling fraud
This rest of this website (and also the books written by Mr. Hesch) take you step-by-step through the process of reporting unbundling fraud against Medicare and how to report unbundling fraud to get a whistleblower reward.
Mr. Hesch is experienced investigating unbundling fraud against Medicare. He worked over 15 years in the Civil Fraud Section of the U.S. Department of Justice in Washington, D.C. handling Medicare fraud cases. He is available to review your case and help determine whether you should and how to report fraud against Medicare by unbundling fraud schemes.
The link below “Do I have a case” shows you how to ask Mr. Hesch to review your Medicare unbundling fraud case and how to get a reward for reporting unbundling.
The link below “Report Fraud” has more information regarding how to get a reward for reporting unbundling fraud against Medicare or Medicaid.