Upcoding and CAPITAL LETTERS – a New Way to Commit Billing Fraud

Healthcare fraud has reached epidemic levels in the United States. At times, the situation has become so bad that the Centers for Medicare and Medicaid Services (CMS) had to resort to drastic measures such as a moratorium on licensing new providers! That means the agency didn’t have the time to license new providers because all its resources were concentrated on rooting out bad providers.

In recent years we have seen these measures in Detroit, Houston and Philadelphia. When that happens, healthcare suffers. Legitimate doctors and providers are prevented from treating patients because the agency doesn’t have the time to screen their qualifications.

Phony billing can occur in many ways. We have an entire information page dedicated to these Medicaid fraud billing schemes. Popular billing frauds include billing for services not provided, unbundling, billing for unqualified providers, submitting claims for ineligible patients, double billing, and upcoding. This post discusses a particular method of upcoding.

Upcoding occurs when a provider bills for a higher level of service than provided. Let’s say that you go to the dentist and need a simple filling. You get your filling but the dentist uses a billing code for a root canal. The patient is no wiser and the dentist pockets more money.

The only problem is that health insurance rates skyrocket. If it is Medicaid footing the bill, taxes go up. There really is no such thing as a free lunch.

Upcoding is common but brings a unique set of problems to the provider. Record keeping. The doctor / dentist / clinic needs to keep accurate notes about the patient’s care yet the notes also must justify the billing code submitted for reimbursement.

Two sets of medical records? That is risky and time consuming. Fraudsters have developed many methods to cover their tracks when upcoding. We have often marveled at some of these elaborate schemes. Some providers are just lazy and don’t even cover their tracks. Others use “cut and paste” notes. 

A whistleblower recently reported that the physician she works for has a unique method of committing billing fraud yet maintaining accurate records. Upper and lower case notes!

Criminals can be ingenious. We wish, however, that they focused their efforts on being better doctors or technicians instead of ripping off patients and taxpayers.

Here is how the scheme works.

The nurse or technician records accurate patient treatment and assessment notes in lower case. A billing specialist later adds notes in upper case – CAPITAL LETTERS – to justify higher billing codes. Should an issue later arise, people in the practice know that only the notes written in lower case letters are accurate.

Ingenious. And illegal.

Upcoding is a crime. Anyone who rips off a patient, insurance company or Medicare through false billings is guilty of a crime. In fact, healthcare fraud is a federal felony punishable by a decade in prison. If a patient dies or suffers harm because of the practice, the sentence can be much longer.

Not only is upcoding illegal, it is often dangerous. If a patient switches providers, how is the new doctor to know which notes are accurate and which ones are false. As we move to a national system of electronic healthcare records, the need for accurate records becomes even more critical. And upcoding using phony notes becomes more dangerous.

Cash Rewards for Whistleblowers

Under the federal False Claims Act and 29 state laws, whistleblowers who report Medicaid or Medicare billing schemes are eligible for large cash rewards.

The government can pay whistleblowers up to 30% of what they recover from wrongdoers. Getting a reward is simple but you need to be the original source of information and you need to be able to show the fraud is part of a larger pattern or practice.

What does that mean? Most whistleblowers who receive rewards are healthcare professionals. They are present or past employees of these doctor’s offices, hospitals and clinics. A patient can report Medicaid fraud – we encourage it! – but unfortunately probably won’t receive a reward. That is because they do not have enough information to show that the phony billings and upcoding is part of a larger pattern of fraud.

If you are a patient we can help you evaluate if you have enough information to receive a reward and if not, still help you report the wrongdoing. When your local state Medicaid Fraud Control Unit gets enough patient complaints, they frequently audit the suspected provider.

To claim a reward, you need a lawyer. We will help you connect with an experienced lawyer. There is usually no fee or obligation unless you recover money. Talking to a lawyer may sound intimidating for some but it shouldn’t be. Qualifying for a reward means filing a sealed lawsuit in court. There are lawyers who handle these cases, worry about any hassles and front all the costs.

Each year the federal government issues hundreds of millions of dollars in rewards. These rewards are very real and you could be next to receive one if you have inside information about illegal upcoding or other billing schemes involving Medicare or Medicaid. (There are rewards for private health insurance fraud in Illinois and California.)

By pursuing these fraudsters, you save taxpayers money, you make yourself eligible for a reward, you help rid the healthcare profession of greed and corruption… And most importantly, you protect patients.

Healthcare Workers Are the First Line of Defense Against Upcoding and Medicaid Fraud

Are you ready to make a difference?

To learn if you are eligible for a reward, contact the Coalition online or by phone 888-742-7248. Our operators will connect you with a qualified lawyer and the calls are confidential. (Please do not contact us from a work computer, work email address or phone.)


Medicaid Fraud Hotline: 888.742.7248 or Report Online
and claim reward