Grand Rapids Coding Errors Lawyer

To bill federal medical benefits programs for reimbursement, health care providers must complete extensive claims that require a great deal of intensive paperwork. This includes assigning the correct billing codes to each claim. When a provider utilizes incorrect billing codes, allegations of federal health care fraud may arise even if using the wrong codes was inadvertent or unintentional. If you are facing charges of fraudulent billing practices, you may want to consider contacting a Grand Rapids coding errors lawyer for advice.

Various types of coding errors in claims for reimbursement by medical providers can lead to federal prosecution under the FCA. From just using the wrong code to sophisticated coding errors schemes, medical providers may be liable both civilly and criminally if they receive payments from federal benefits programs in error. These programs include Medicare, Medicaid, or Tricare. If you are facing federal civil or criminal charges, a seasoned health care fraud attorney can help.

Billing and coding errors are one of the most common types of federal health care fraud. This has led to many prosecutions—primarily under the False Claims Act (FCA)—of medical providers of all sizes and from all areas of the United States.

The FCA contains a broad prohibition on making any false statements or misrepresentations of fact to obtain payments from a federal health care benefits program to which they are not entitled. A claim for reimbursement based on a coding error qualifies as a “false claim” for the FCA.

The civil enforcement mechanisms in the FCA do not require any evidence of ill intent. Consequently, a purely mistaken coding error still constitutes fraud against the government and triggers the civil liability provisions of the FCA, meaning that the provider would have to return any reimbursements received as a result of coding errors.

If the Department of Justice (DOJ) finds evidence of intentional miscoding of claims for medical services or equipment, it can also pursue criminal charges against the medical provider. This may result in high fines and penalties, as well as a sentence of incarceration in federal prison. In this situation, consulting with a coding errors lawyer in Grand Rapids may be useful.

One typical example of a coding error is upcoding. In this situation, providers routinely submit codes for items or services that are reimbursable at higher rates than the items or services provided. A similar type of error is unbundling, through which providers separate claims for services in violation of guidelines that require certain services and supplies to be bundled and claimed at a lower reimbursement rate.

Another related coding error is adding modifiers to billing codes. The Centers for Medicare and Medicaid Services (CMS) permit the addition of modifiers only in very isolated and specific situations. When providers add inappropriate modifiers to billing codes to get higher reimbursement rates, they commit fraud in the eyes of the U.S. government. For more information, contact a knowledgeable defense lawyer.

The FCA permits the DOJ to pursue civil or criminal penalties against health care providers that violate its terms. When there are no allegations of intent to commit fraud, health care providers are more likely to face civil penalties. These penalties may include thousands of dollars in fines for each false claim, treble—or triple—damages, and reimbursement of the value of the false claims.

If the DOJ finds evidence of intent on the part of a medical provider to submit improperly coded claims designed to defraud a federal benefits program, criminal prosecution can occur. Potential fines may result in hundreds of thousands of dollars in fines and years of incarceration for each false claim. A qualified coding errors attorney in Grand Rapids may be able to help with either type of charge.

The ramifications of either civil or criminal sanctions for improperly coded claims seeking reimbursement from federal benefits programs can be severe. Incarceration, loss of medical licenses and hospital privileges, and non-payment of future claims all may result, in conjunction with thousands in fines and penalties.

A Grand Rapids coding errors lawyer can help defend individuals against accusations of wrongdoing and work to minimize the impact of these accusations on your personal and professional life. Call today to learn more.