Under both the Medicare and Medicaid programs, the government requires all healthcare providers to use standardized billing codes to identify the services provided when they submit claims for payment for those services.  Upcoding occurs when a provider knowingly alters the billing code for a health care service, treatment, diagnostic test or other billable item to a code for a more expensive health care service, treatment, diagnostic test or billable item than was used or medically necessary and bills the government using the code for the more expensive item.  This fraudulent billing practice is an intentional manipulation of the government’s billing procedures and causes the government to pay more than it should for the actual diagnosis and treatment of the patients.  It is also a potentially fast-growing kind of fraud because electronic medical records and electronic billing provide mechanisms for these changes to be done quickly and with virtually no paper trail.

Healthcare providers who engage in upcoding and submit claims for payment for more expensive care than what they actually provided may be submitting false claims for payment to the government in violation of the False Claims Act (“FCA”).    

If you believe someone has knowingly engaged in upcoding and you would like more information about how this may be the grounds for bringing a Medicare or Medicaid whistleblower lawsuit, the qui tam lawyers at Keller Grover LLP can help you.  The whistleblower lawyers at Keller Grover understand qui tam litigation, including the whistleblower protection provisions, and strive to achieve the best possible results for their clients.