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When medical facilities bill procedures that should be grouped together separately in order to maximize profits, a whistleblower can bring this case of illegal unbundling to the government’s attention.

Defining Unbundling

When any patient visits a doctor or healthcare facility, several procedures might be recommended or performed at once. For these treatments commonly grouped together, reimbursement to doctors is managed through different coding than if each procedure were billed separately. Providers must properly code all procedures done in their office to receive compensation from Medicaid or Medicare.

The FBI defines unbundling as the practice of submitting bills in a fragmented fashion to maximize reimbursement for procedures or tests that should be billed together at a reduced cost.

Therefore, unbundling refers to the practice of improperly coding a medical procedure provided to a patient in order for the physician or a provider to reap greater reimbursement payments. This means that the service name on the insurance paperwork is not in line with what the patient actually received. Unbundling is a separate type of upcoding practice. This involves billing for individual procedures that are typically billed together under a single CPT code and also performed together.

Current procedural technology refers to the codes established by the American Medical Association to describe various treatments and procedures. When doctors provide a patient with treatments that should have been billed together, this can lead to higher levels of reimbursement but also triggers a False Claims Act case.

Unbundling happens when a health care provider submits every component within a CPT to Medicaid or Medicare separately, generating a cost redundancy where the fraudulent filer can illegally seek reimbursement for the same procedure several times over.

This process can also be referred to as fragmentation. Lower Medicare and Medicaid reimbursement rates are often associated with groups of procedures that are performed together; such as the incision or the closure associated with a surgery.

The use of electronic medical records software can facilitate fraud such as unbundling and upcoding. This is because providers can easily copy and paste notes from a prior visit with the patient into the current treatment note, making it seem as though the provider has treated and diagnosed every condition on that list.

Sometimes the menus on the electronic health record software used by a health care facility can even be manipulated and restricted to show only the treatment codes and diagnoses with the highest reimbursement rates.

Unbundling and Whistleblower Suits

Unbundling is one form of fraud against the government that could lead to the filing of a whistleblower case. A whistleblower might identify and report unbundling to the government or other relevant authorities and this could become the beginning of a case under the False Claims Act.

Discovering illegal practices such as upcoding or unbundling in a professional capacity puts you in a difficult situation. As a whistleblower, you could be eligible to recover a partial reward in the event that your unbundling case leads to recovery of compensation on behalf of the government. The False Claims Act enables individuals with information to take a stand in alerting the government to and stopping health care fraud. The government will evaluate the details and opt whether or not to intervene.

With the assistance of a lawyer such an employee or person can file a qui tam lawsuit under the false claims act, formally triggering a government investigation. The government will complete their investigation and decide whether or not to continue in the case.

After the case is brought forward with whistleblower information, the government will conduct an investigation to determine whether or not there appears to be enough merit to continue with the case.

If the government is successful in bringing an enforcement action and recovering substantial sanctions, the individual who raised these concerns could be eligible to receive between 15% and 20% of the amount the government recovers because of a qui tam lawsuit.

Other Protections Given to Whistleblowers

Whistleblowers who bring helpful information to the government about practices of unbundling and upcoding will also receive protections under the False Claims Act as it relates to employer retaliation. Billing Medicaid and Medicare for medical supplies and services is done using a complicated system of codes designating various procedures and diagnoses.

The reimbursement for each of these supplies and procedures is based on the codes submitted. The computerized and coded bills submitted by providers are then processed by insurance companies that contract with the US government to pay out claims using taxpayer funds.

Medicaid and Medicare offer different reimbursement rates for common procedures completed together, such as a blood test panel done by a clinical laboratory.

If you think you have details about a company or physician’s practice of manipulating coding, consider consultation with a whistleblower lawyer to discuss your rights.

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