# Upcoding is a violation of what code of US Law?



## southbaymed (Mar 4, 2012)

at the injection (swine flu vaccine) for new patient, one of my provider charged w/99202
$110 without facing the patients. 2nd shot $65. He is non-par. One day he has 54 patients(all young children) which I was told 2 month later and shocked and depressed me that I might be involving the wrong doing. I could not sent the balance bill to the patient(after ins.company paid). Now he is suing me for $5000 damage. I explained in the court about
the upcoding practice; however the judge's response was "so what" and ordered me to
pay $5000.  The case was appealed to superior court.
I need the Violation code to US government law to convince the judge that he never lost
any money if he has been doing last 10 years. Thank you


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## ollielooya (Mar 4, 2012)

I hope you have a good experienced attorney who is familiar with medical law and that you are not attempting to fight this alone.  Sounds like there may be additional issues going on here.  I'm hoping that others who have been thru similar ordeals in this forum will step in to provide valuable advice...this is a frightful ordeal to have to go thru!  Will be following this thread with keen interest.

---suzanne E. Byrum CPC


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## mitchellde (Mar 4, 2012)

southbaymed said:


> at the injection (swine flu vaccine) for new patient, one of my provider charged w/99202
> $110 without facing the patients. 2nd shot $65. He is non-par. One day he has 54 patients(all young children) which I was told 2 month later and shocked and depressed me that I might be involving the wrong doing. I could not sent the balance bill to the patient(after ins.company paid). Now he is suing me for $5000 damage. I explained in the court about
> the upcoding practice; however the judge's response was "so what" and ordered me to
> pay $5000.  The case was appealed to superior court.
> ...



To bill a service not documented is a violation of the false claims act.  Start there.  You should have had an attorney from the start that understood the principles of health care and billing practices.


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## btadlock1 (Mar 4, 2012)

southbaymed said:


> at the injection (swine flu vaccine) for new patient, one of my provider charged w/99202
> $110 without facing the patients. 2nd shot $65. He is non-par. One day he has 54 patients(all young children) which I was told 2 month later and shocked and depressed me that I might be involving the wrong doing. I could not sent the balance bill to the patient(after ins.company paid). Now he is suing me for $5000 damage. I explained in the court about
> the upcoding practice; however the judge's response was "so what" and ordered me to
> pay $5000.  The case was appealed to superior court.
> ...



Intentional upcoding violates the False Claims Act. If it was submitted electronically, it could also be construed as wire fraud. When you submit a claim, you certify that every code billed, is supported by medical record documentation, which is impossible' if you've upcoded. Also, balance billing patients is probably a breach of your payer contract...if any gov't beneficiaries were balance billed, that's also illegal, per the SSA. If I were you, I'd get a lawyer...


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## southbaymed (Mar 7, 2012)

*Do you know any speciality lawyer?*

Hi thanks to everybody.  Bcz we have been educated by AAPC, it is so obvious that up-coding is illegal practice; however to explain to the outside of world(capitalistic world), it takes time. For lawyer to explain this portion costs money, too.  I am talking with one lawyer who is very enthusiastic, but found that I need to take time to explain why this is wrong.
If I can provide the violation code to him, I feel I can save a little money. It will cost more than $2500 just to defend myself and he says he is not sure if he can win?? I am southern California, if anyone know the lawyer who understanding this matter?.


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## ollielooya (Mar 7, 2012)

You are in a very tough position and do not jeopardize your position by hiring an attorney who is NOT experienced in this field.  Why should you have to be the one to educate him?  Goodness, no.   If you had a medical condition that required the services of a specialist and even though your doctor was a great practictioner and "could" do the procedure, wouldn't you feel more secure with one who specialized in the treatment needed?   The lawyer you're considering might be an excellent attorney, but you really need one who is experienced and confident in this line of work IMO.  Here's a weblink forum where you might get some advice from people in the know for Medical Office Managers and the like, but it is moderated by a very well known consultant and there are many "power players" on his list.  You'll have to join, but you'll run into a lot of your colleagues from the Academy as well.  Post your question there and you'll no doubt get responses and advice.  ---Suzanne E. Byrum CPC.  

http://health.groups.yahoo.com/group/Med-Managers/?yguid=70123704


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## southbaymed (Mar 9, 2012)

Hi Suzzane
Thank you very much for your advice.  I joined the group & posted the Q and got responses quickly. Some of them are very helpfull and encouraging.  But since yesterday
afternoon, I tried to visit the site and looks like freezed?? I am very eager to access again
bcz I am asking any specialized lawyer in my area. I am in so called "southbay area" in
the Los Angeles county.
I will keep post this case progress for us.
tks


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