Switch to ADA Accessible Theme
Close Menu
Home > Healthcare Law > Medicare Fraud Defense > Unbundling Defense

California Unbundling Defense Lawyer

Unbundling occurs when the various components of a medical procedure are billed separately to Medicare, but the entire procedure was supposed to be billed as one procedure under one billing code. Sometimes the various parts of a procedure are performed separately, so it is proper to bill them separately. Other times, billing staff might make a mistake and overbill Medicare by separately billing different parts of the procedure when they shouldn’t. The government might not see it as a simple mistake, however. They might see it as Medicare fraud instead. The consequences can be severe for you and your medical practice, putting you at risk of civil enforcement proceedings or criminal prosecution, which could cost you untold monetary penalties, suspension or loss of your medical license, reputational harm, or years in prison.

See below to learn more about the practice and perils of unbundling medical services, and call the Law Offices of Art Kalantar in Beverly Hills if you are being investigated or prosecuted for healthcare fraud based on unbundling or other coding errors. Our healthcare law practice defends people charged with unbundling offenses in Los Angeles and statewide, so call our experienced California unbundling defense lawyer today for a free case evaluation and immediate help.

How Unbundling Errors Can Happen

Healthcare providers receive a large part of their revenue through reimbursement for services from Medicare and Medicaid (Medi-Cal in California). To standardize the reporting and billing of medical services to Medicare and Medicaid (and private payers like insurance companies as well), the American Medical Association (AMA) created a system of codes known as Current Procedural Terminology (CPT) codes. These codes cover every billable procedure imaginable, and the list of codes is enormous. What’s more, the list of CPT codes is constantly changing. New codes get added every year as new services appear, some old codes disappear, and the codes for existing procedures get reorganized and reclassified.

The AMA revises and updates CPT codes on an ongoing basis; the process never ends. And it’s not just the codes that change; the coding guidelines themselves are continually being revised, changing the way codes are reported and the proper medical terminology and nomenclature to be used. Preventing coding errors at your practice requires that you ensure your billing staff are constantly trained and updated on the most current CPT codes. Whether you have a large, bustling practice or a small billing staff, it’s no wonder that mistakes can slip by.

Unbundling is a special subset of coding mistakes. As mentioned, every procedure imaginable has a CPT code attached to it. Some procedures – most procedures – will involve more than one billable service each with its own code, but the overall procedure itself may have its own code as well. Unbundling occurs when the provider bills for the constituent services rather than using the one code that covers the entire procedure. It’s up to your staff (and ultimately the owner) to know when a procedure is covered by one code that should be used over others in the ever-shifting world of Medicare billing.

Medicare has a system in place to help it catch unbundling mistakes. This system, the National Correct Coding Initiative (NCCI) Edits, is designed to notice when certain codes are billed together that ordinarily should not be. If your practice bills a pair of such codes for the same patient on the same day, the NCCI Edits are intended to catch the error and refuse payment. In most cases, the result will be that the provider will need to resubmit the reimbursement request with the appropriate code. Unfortunately for the provider, this mistake might also get flagged as a fraudulent billing practice, kickstarting an investigation and enforcement action from federal agencies such as the U.S. Department of Justice (DOJ), the U.S. Department of Health & Human Services (HHS), the HHS Office of Inspector General (OIG), and the Centers for Medicare and Medicaid Services (CMS). Members of your own staff might even think the unbundling was done intentionally and fraudulently, leading them to file a False Claims Act (whistleblower) lawsuit on the government’s behalf, with your own employee collecting a portion of any monetary judgment or settlement levied against you.

Get Help From an Experienced California Unbundling Defense Lawyer Today

California healthcare law attorney Art Kalantar is experienced in defending healthcare practices when they are charged with Medicare fraud based on coding errors. Let the Law Offices of Art Kalantar provide you with the advice and representation you need to get keep your license, your practice, your assets and your freedom, and get the best result when faced with a government investigation or prosecution. Call our experienced California unbundling defense lawyer today for a free case evaluation at 310-773-0001.


Share This Page:
Facebook Twitter LinkedIn