UPCODING AND OTHER HOSPITAL FRAUD
Over the past couple of weeks, the Federal Courts have passed on a spate of fraud allegations against hospitals. In the past, New Jersey hospitals have been hit with similar claims and, in fact, some New Jersey hospitals have settled with the Federal Government for these allegations of fraud. The claims allege what amounts to improper or inflated billing practices. The terms of art for inflated billing is “upcoding”. Upcoding is basically where the hospital bills for a procedure which may have been more intricate and provides for a larger reimbursement from the Federal Government. The “upcoding” refers to a different billing “code” that the Federal Government assigns to certain procedures. By submitting a claim for a more difficult or intricate procedure, the hospital is reimbursed a larger amount of money. Although there are variants on this upcoding issue, a qualified fraud attorney can explain the intricacies.
“Upcoding” can occur in hospitals as well as physician’s offices, nursing homes or, for that matter, dental offices and counselors’ offices. The upcoding can come in the form of billing for a more difficult procedure but it can also come in the form of billing for a longer procedure. For example, a false claim was brought against a counselor for billing for one-hour sessions when in fact the sessions were only lasting 45 minutes. After the fraud was reported, the investigators engaged in some simple math. The accumulation of the hours billed by the professional far exceeded that which was possible.
The claims for upcoding can be very difficult to prove and nearly always require documentation. Basically, the report of fraud would have to be made by someone who had specific and direct knowledge of the actual procedure that was performed. Very often, these cases are reported by nurses or other professionals who are directly involved in patient care. The delicate balance is reporting the factual basis for the “upcoding” violation without violating privacy rules of the patient.
If you have been witness to, or are concerned about, upcoding violations in New Jersey, you should speak to a qualified New Jersey Whistleblower lawyer.