A recent article in Part B News, “Be careful about upcoding; DOJ may come after it as a false claim,” discussed how the U.S. Department of Justice frequently prosecutes improper billing of CPT codes for Medicare patients. Rivkin Radler’s Jeff Kaiser was quoted in the article.
“Sometimes, a provider will upcode a diagnosis code to justify billing for a particular medical service or to obtain higher reimbursement under the Medicare Advantage Program for an allegedly ‘sicker’ patient population,” Jeff said. “And sometimes, a provider will intentionally misdescribe the service performed so that it will be paid by insurance — e.g., performing a ‘nose job’ (rhinoplasty) but billing for a deviated-septum repair. All of these forms of misconduct have been prosecuted at one time or another and, depending on loss amount and other factors such as any public health risk that may exist, the government does not require any additional justification — such as additional billing misconduct — to move forward.”
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