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Florida Unbundling Fraud Lawyer

Healthcare providers use a special code set, known as Current Procedural Terminology (CPT) when billing insurers for medical services provided to patients. Under this system, medical, surgical, and diagnostic services are assigned specific codes, each of which is given its own cost for billing purposes. Unfortunately, the use of these codes can make it easier for many healthcare providers to engage in fraudulent and deceptive practices like unbundling, wherein a provider charges Medicare or Medicaid a separate price for groups of procedures that are usually performed together. Healthcare providers who are found to be engaging in this type of conduct can be held accountable in federal district court, so if you recently discovered irregularities in your employer’s billing practices, please call our experienced Florida unbundling fraud lawyers today for help.

What is Unbundling Fraud?

Some medical services, primarily those that are typically performed together, are “bundled” together and charged as one service. Incisions and closures that are incidental to surgery, for instance, are typically billed together under the same code. Medicare, Medicaid, and other government programs, however, often have lower reimbursement rates for groups of procedures. In an effort to charge more than these lower prices, some healthcare providers engage in a practice known as unbundling, which involves billing group procedures separately, thereby increasing what they receive in reimbursement from Medicare and Medicaid. Using billing codes for two or more separate procedures when services were actually performed together results in the loss of billions of dollars in government funds every year.

Examples of Unbundling

As mentioned earlier, surgical procedures typically involve an incision at the beginning of the procedure and closures when the surgery is complete. Because these two services occur during the same procedure, they are often bundled together during billing, resulting in a lower price. It is possible, however, for closures to be performed as a separate procedure. If, for instance, a patient came into the hospital with a preexisting wound, he or she might only require a few stitches. In these cases, the healthcare provider would bill this as a separate service, the cost of which is often higher than a bundled service. Unfortunately, some unscrupulous providers choose to bill one procedure as multiple procedures. In the above example, this would involve billing the incision and stitches performed during a surgery separately.

Similarly, when a patient gets his or her blood work done, the service usually involves a preset collection of tests, which are charged at a predetermined rate. Each test within the collection, however, also has an individual billing rate to be used in the event that a patient doesn’t need a complete work-up done. If a hospital were to perform a blood panel, but charge the group of tests as individual blood tests, it would be engaging in unbundling, which is considered a form of healthcare fraud. 

Consult with a Florida Unbundling Fraud Lawyer

The False Claims Act gives employees who have knowledge about a healthcare provider’s fraudulent billing practices to report that fraud to the authorities and potentially receive a reward in exchange. Please call 561-659-7878 to learn more from the experienced Florida unbundling fraud lawyers at Rabin Kammerer Johnson today.