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DC Federal Healthcare Unbundling Lawyer

Certain healthcare services are “bundled” by insurers, which means groups of related medical treatments must be billed under one payment code instead of each treatment being billed separately. Law enforcement agencies and insurance companies are always looking for situations in which   each part of the treatment is billed separately, or “unbundled,” instead of being grouped under the inclusive single code, as it increases the money flowing to a provider.  This is also known as “code fragmentation.” Law enforcement often treats this alleged activity as a form of healthcare fraud. If you are being investigated for or have been accused of unbundling, a DC federal healthcare unbundling lawyer can provide advice on your options.

DC Federal Unbundling Investigations

Investigations into unbundling can start in a variety of ways.  The Centers for Medicare and Medicaid Services (CMS) has systems to identify errors, fraud, and abuse. The Center for Program Integrity was created in April of 2010 to coordinate efforts to investigate improper payments to providers. CMS may deny claims due to unbundling or may collaborate with law enforcement if there is reason to believe the unbundling was intentional abuse or fraud rather than error.

Unbundling also comes to the attention of authorities via whistleblower lawsuits filed under the False Claims Act. Individuals with purported knowledge of fraudulent behavior, or a bias against a particular provider, are incentivized to sue because they may receive a portion of any money recovered by the U.S. government in connection with Medicare, Medicaid, or Tricare fraud.

Consequences of Unbundling

Unbundling can result in large fines and potentially lengthy jail sentences making it imperative that a DC federal unbundling lawyer is contacted as soon as possible.

18 U.S.C. 1347 establishes a penalty of up to 10 years of incarceration for healthcare fraud, which is defined as willfully or intentionally becoming involved in a scheme to:

  • Defraud a health care benefit program in connection with delivery of care or payment for care OR
  • Obtaining money or property under the control of a health care benefit program through the use of misrepresentations, false promises, or false pretenses in connection with the delivery of healthcare benefits or payment for healthcare services.

Intentionally submitting unbundled claims for purposes of recovering more compensation than would otherwise be available can be considered a form of fraud or material misrepresentation.

18 U.S.C. 24 makes clear that a healthcare benefit program includes not just government programs like Medicaid, Medicare, and Tricare, but also private insurance.

Other federal laws may also apply when unbundling occurs:

  • 18 U.S.C. 1035 forbids making false statements, lying about, or covering up material facts in connection with delivery of health services or payment for healthcare benefits. Penalties include fines and up to five years of incarceration.
  • 18 U.S.C. 1518 forbids obstruction, or attempted obstruction, into a criminal investigation to identify health care fraud. Penalties include up to five years of incarceration.

The government is given wide latitude to secure injunctions against fraud and to freeze the assets of someone suspected of committing a fraud offense. 18 U.S.C. 1345 addresses injunctions and 18 U.S.C. 982 addresses forfeiture of personal and real property obtained directly or indirectly through the commission of healthcare fraud.

Contacting a DC Federal Healthcare Unbundling Lawyer

A DC federal healthcare unbundling lawyer can represent you if you are under investigation for or formally accused of unbundling.  An federal healthcare unbundling attorney in DC can work with you to present one of the numerous defenses to this accusation, which may include showing that there was no willfulness, or intent to do anything illegal, that someone else was in fact responsible for the unbundling, or that in fact no unbundling occurred.

Contact a DC federal healthcare unbundling lawyer as soon as possible for the opportunity to have a knowledgeable advocate in your corner when healthcare fraud accusations are at stake.

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