Medicare, Medicaid and other programs
Billing fraud in health programs
Public programs pay on the codes a provider submits. When the codes do not match the care, someone inside usually sees it first.
Upcoding
A higher-paying code than the service delivered.
Unbundling
One service split into several bills to pay more.
Care not needed or not given
Tests, visits or equipment billed without a reason or without being provided.
Kickbacks and referrals
Payments or perks for sending patients where the program pays.
Eligibility games
Patients enrolled in hospice or home health who do not qualify.
Staffing and quality claims
Billing for staffing levels or care the facility did not provide.
What we check before we say yes
We read the records with a coding consultant or a clinician before taking a case. Most reports do not become cases: sometimes a practice bills aggressively but within the rules. We tell you which, and why.
What helps
- The codes or claims you saw, and what the care actually was
- Dates, and who approved the billing
- Any policy or instruction you were given about how to code
- Whether you raised it inside, and what happened
Bring what you saw in doing your job. We will talk about the rest before you copy anything.
Start from a code, a date, a name.
A few sentences about what you bill, code or approve, and what changed.
Contingency fees come from any recovery. Costs such as filing and expert fees may be separate; we explain them in writing before you sign.