We work with whistleblowers to expose fraud against the government.

Unbundling

Medical providers use improper billing codes to fraudulently maximize Medicare and Medicaid payments.

Several popular fraudulent scams involving Medicare and Medicaid center around the use of improper billing codes. To comprehend the scam, it is necessary first to understand the complex system of numerical codes by which medical providers bill Medicare and Medicaid.

Each medical procedure and diagnosis is assigned a different numerical code on the computer-generated bills prepared by the medical providers. Those bills are forwarded to “intermediaries” or “carriers” — large insurance companies retained by the government to process the bills and make payment to the medical providers with government funds. The amount received by a medical provider is determined by the particular procedure and diagnosis codes contained in the provider’s bill.

Medical provides may overbill by unbundling medical procedures and charges that should be billed together at a lower rate.

One common type of fraud in the coding process is known as “unbundling” or “fragmentation.” Medicare and Medicaid routinely pay a lump sum reimbursement rate for a group of procedures that are usually performed together; the reimbursement rate is lower than if the same tests had each been performed separately.

A typical example involves blood test panels conducted by clinical laboratories, in which single blood tests are used to test for several different things. To increase their profits, some health care providers “unbundle” the combined tests into separate “fragments” and bill separately for each element of the group, resulting in higher reimbursement rates.

Examples of unbundling include the following:

  • In August 2007, Maryland cardiologist Pradeep Srivastava agreed to settle claims of Medicare fraud against him for a total of $476,000. Srivastava allegedly committed Medicare fraud over a period of three and a half years.
  • The allegations against Srivastava included billing for services that he did not provide; upcoding, or billing for a level of service higher than that provided to the patient; and “unbundling,” or billing separately for the component parts of a procedure rather than using the appropriate comprehensive CPT code.
  • Genesee Valley Cardiothoracic Group was accused of fraudulently billing Medicare for services of assistant attending surgeons to be present during surgery. Because there were qualified cardiothoracic residents present, however, Medicare regulations prohibited charging separately for assistant attending surgeons.
  • Billing separately for the assistant attending surgeons constituted false claims under the federal False Claims Act, claimed the government. Genesee Valley Cardiothoracic Group agreed to settle the claims against it for $2 million.
  • The whistleblower, who brought the qui tam lawsuit that brought this fraud to light, was entitled to share in the ultimate recovery.

Medical providers have a financial incentive to unbundle charges.

By unbundling the various components of a medical treatment and billing for them separately, medical providers fraudulently recover higher reimbursement from Medicare and other programs. Whistleblowers can help bring such fraud to light.

What is Qui Tam?

Under the Federal False Claims Act (FCA), whistleblowers have the power to save taxpayers billions of dollars each year by taking a stand against fraud. The U.S. False Claims Act allows private citizens to file suits on the government’s behalf when the government has been defrauded through any federally funded contract or program. The qui tam provisions of the False Claims Act allow these citizens to recover damages. A number of states and the city of Chicago also have laws similar to the False Claims Act to protect against fraud. To learn more about the different types of fraud … READ MORE

Legal Issues for Exactech Mount With 40K More Recalls and False-Claims Act Suit

January 26, 2023 Exatech Inc. has expanded its hip recall to include another 40,000 components that may be defective following an earlier recall of nearly 250,000 knee, hip, and ankle replacements over the past year because of problems with polyethylene liners. These recalls…

Waters & Kraus founders named to 2022 Texas Super Lawyers list

December 1, 2022 Waters & Kraus LLP is proud to announce that law firm partners C. Andrew Waters and Peter A. Kraus once again have been named to the 2022 Texas Super Lawyers list. The prestigious list recognizes both Waters and Kraus as among the top 5% of Texas attorneys in their practice areas for personal Injury litigation and product liability litigation on behalf of plaintiffs. About Super Lawyers® Super Lawyers is a Thomson Reuters rating publication that annually conducts a rigorous review process to name outstanding lawyers in more than 70 practice areas. The selection process involves peer input and third-party validation…

What are my chances?

That’s the first question everyone asks. The truth is it’s impossible to know. But we can tell you this. Waters Kraus & Paul has what it takes to fight against big corporate interests and win. That’s why we’ve taken more mesothelioma trials to verdict than any other firm. And that’s why we’ve recovered more than $1.3 billion for clients like you. Do you think you have a case? Contact us now to speak with an attorney.

Call 800.226.9880