Are You Defrauding Medicare By Either Upcoding Or Downcoding Submitted Claims?

Posted by donna@healthlawcenterplc.com in Aug, 2018

Both upcoding and downcoding are significant because these actions have been interpreted as a basis for abusing and defrauding the federal government and its programs. According to CMS, “abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program.” Abusive coding practices include:

• Upcoding – a code with a higher reimbursement rate despite not providing the service or meeting the medical necessity requirement
• Downcoding – a lesser code on a claim, perhaps to induce patients to keep coming back for other services
• Excessive charges for services or supplies.

The aforementioned abusive coding practices are illegal. Laws that may be implicated include the False Claims Act, Anti-Kickback Statute, Stark Law, Social Security Act, and the United States Criminal Code. The U.S. Department of Justice (DOJ) has both prosecuted and settled cases where physicians and other providers have defrauded the government by not meeting medical necessity, using modifiers that were not appropriate and resulted in higher reimbursement, and overcharging for goods (i.e., durable medical equipment) and services.

For a better understanding of how to properly document medical services and the proper use of modifiers, contact Donna J. Craig, RN, JD at The Health Law Center.

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