Healthcare providers bill medical procedures under codes known as current procedural terminology (“CPT”) codes. When the medical bill is sent to Medicare or Medicaid, the CPT code determines how much the healthcare provider gets paid. “Upcoding” refers to the practice of assigning a code which artificially increases the rate of pay for the provider. It is a simple and effective fraud and, without a whistleblower coming forward to stop it, can be almost impossible to detect. Similarly, the billing of government healthcare programs for services not actually rendered or services that were not medically necessary, is also fraudulent.
Our attorneys have represented whistleblowers in a successful upcoding case, for example, Commonwealth of Massachusetts v. Metromedic Health Center, a case in which Dr. Tushar C. Patel and his businesses settled whistleblower allegations that the clinics had been billing for unnecessary diagnostic tests as well as upcoding certain CPT codes. The clinics and Dr. Patel also entered into a corporate integrity agreement.