Upcoding is Not Uncommon – But These Guys Got Caught

Why get paid less when all you have to do is change a few numbers on a claim form and you’d be driving a cadillac by Xmas……………

$750K Settlement Reached with Texas Physicians Group over False Claims

June 24, 2021

The U.S. Justice Department has reached a settlement agreement with a physicians group in El Paso over allegations of violating the false claims act.

The U.S. Attorney’s Office for the Western District of Texas reported that El Paso Ear, Nose & Throat Associates (EPENT) has agreed to pay $750,000 to settle allegations that they violated the False Claims Act by billing Medicaid, Medicare and other federal healthcare programs by upcoding evaluation and management codes.

The government alleged that EPENT knowingly caused false claims to be submitted to federal healthcare programs by billing for services at a higher rate of reimbursement than they would be entitled to for the service actually provided. This scheme is commonly referred to as “upcoding.”

The Defense Health Agency (DHA) supports the delivery of TRICARE, the program that provides integrated, affordable, high-quality healthcare services to more than 9.6 million uniformed service members, retirees and their families. TRICARE was one of the government health programs that was defrauded in this case.

The matter was investigated by the FBI, U.S. Department of Health and Human Services Office of Inspector General, Defense Criminal Investigative Service and the Texas Attorney General’s Office Civil Medicaid Fraud Division.

The claims asserted against the defendants are allegations only; there has been no determination of liability.

Assistant U.S. Attorney Eduardo R. Castillo handled this matter.

Source: U.S. Attorney’s Office for the Western District of Texas