Have You Heard of Upcoding? It’s a Big Part of Medical Fraud


19 November 2016


What does the term “medical fraud” conjure up in your mind? Do you picture a questionable-looking character going door to door, soliciting personal information of Medicare beneficiaries? Maybe you see a fake doctor administering tests to unsuspecting patients in a dingy medical facility.

Sure, these exaggerated caricatures aren’t out of the realm of possibility, but it’s often the case that fraud in the healthcare industry is much subtler, to the point that it can occur to almost anyone without their knowledge. It even happens in the sleekest looking medical facilities, and it can be perpetrated by professionals that one would seldom suspect of being a fraudster.

One of the most “subtle” and common forms of medical fraud has a name that belies its simplicity. It’s called upcoding, and while that might sound like a boring, complicated system, it’s quite easy for a medical professional to do.

Upcoding is the practice of billing for services other than those provided. It some cases, it’s essentially just overbilling, and it’s one of the easiest ways for a provider to earn a little extra money without risking being noticed by the authorities or by patients.

Before we look at just how prevalent this practice is, it’s important to understand that virtually every medical service has a code to which it is associated. These codes are very specific, and a provider lists the code of the service they provided their patient either to the patient themselves or to the insurance company that will pay for the service.

When a doctor is guilty of upcoding, it means that they provided a different code than the one representing the service that was provided. While some forms of upcoding are blatant, and could easily be spotted by someone who simply took the time to notice, others are so slight that they would go undetected unless someone was paying close attention.

For example:  You see your doctor for a checkup. You schedule your appointment, sit patiently in the waiting room, see your doctor for about 10 minutes, pay your co-pay and you go home. Meanwhile, your doctor has billed you for pretty much exactly what transpired during your visit, with one major exception. Instead of billing you for the 10 minutes he spent with you, he bills you for a much longer period of time. You likely never looked at your bill, and it would be difficult for an insurance provider to say that he didn’t spend that extra 20 minutes in your presence.

These face-to-face interactions are some of the easiest for a doctor’s office to “fudge” the numbers ever so slightly in a way that is difficult for anyone to dispute. When time or, more specifically, face-to-face interactions are the services being billed for, it leaves a much larger margin for error or, in this case, for fraud.

In addition to face-to-face time, upcoding can also occur when services billed are simply inflated versions of the service provided, whether that be a test or a treatment of a patient. In these cases, even some of the most medically savvy or attention-detailed patients might not catch the fact that they paid for something that doesn’t reflect what they received.

Upcoding is so common, in part, because it is so easy to do without getting caught. Investigators are always on the lookout for upcoding as one of the first signs of a fraudulent medical provider. For the aforementioned reasons, it’s not always easy to discover upcoding without the cooperation of someone who is familiar with the services and billing practices of a facility. This is one of the reasons that whistle blowers are so important to the process, and it’s also one of the reasons that whistle blowers are often employees of the company or facility that has committed fraud.

And that’s the simple story of one the grossest and most widespread forms of medical fraud in the United States. While we don’t know exactly how much money is taken from programs like Medicare because of upcoding, investigators suspect that it is very significant and it is common.

So, pay attention the next time you look at your medical bill. The chances are good that your facility was completely justified in the amount that you were charged, but there is also a slight chance that there is something there that is just a little off – and that slight difference might be part of a larger system that defrauds patients and costs taxpayers vast sums of money.

Bert Louthian is a whistleblower attorney in South Carolina who focuses on helping those who have been wronged, or who have witnessed wrongdoing to come forward to report fraud. He can be reached by calling or visiting his website –thewhistleblowerlawyer.com

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Living Alone

Discusses the Growing Problems of Living Alone

Researchers have concluded that living alone, being socially isolated, and feeling lonely can pose significant health risks, particularly in older adults. Although the terms living alone, social isolation and loneliness are often used interchangeably, they are not the same thing. Specifically, living alone and being socially isolated are objective determinations either that a person lives solo, or has few relationships or infrequent social contact. According to the Administration on Aging (a division within the U.S. Department of Health and Human Services), nearly one-third (28%) of non-institutionalized adults 65 and older – 13.8 million people – live alone. Despite living alone, however, these adults may or may not be included within the category of social isolation depending on the nature of their relationships and the frequency of their social contacts. In contrast, loneliness is determined on a subjective basis. Loneliness is based on a person’s individual feelings of disconnectedness, isolation, or not belonging. Said differently, loneliness arises because of the divergence between a person’s desired level of social connection and the actual level of connection. To be clear, a person living alone may not necessarily feel lonely, whereas someone living with a number of other people may still experience loneliness. Risk Factors A recent survey of older adults determined that 43% feel lonely on a regular basis. More concerning is that among those who report feeling lonely, there is a 45% increased mortality risk. Steve Cole, the director of the Social Genomics Core Laboratory at UCLA, explains: “Loneliness acts as a fertilizer for other diseases. The biology of loneliness can accelerate the buildup of plaque in the arteries, help cancer cells grow and spread, and promote inflammation in the brain leading to Alzheimer’s disease. Loneliness promotes several different types of wear and tear on the body.” Research has established links between living alone, social isolation, and loneliness to a variety of physical and mental conditions, including high blood pressure, heart disease, obesity, a weakened immune system, anxiety, depression, cognitive decline, Alzheimer’s disease, and even death. Indeed, a recent meta-analysis – representing cumulative evidence from 148 studies involving over 300,000 participants – determined that greater social connection is associated with a 50% reduced risk of early death. A second meta-analysis by the same researchers – representing cumulative evidence from 70 studies involving more than 3.4 million participants followed for an average of 7 years – similarly concluded that living alone (objective determination), social isolation (objective) and loneliness (subjective) each had a significant effect on the risk of mortality. Specifically, the analysis concluded that the likelihood of death increased a statistically significant 26% for loneliness, 29% for social isolation, and 32% for living alone. To put those risks in context, the researchers determined that the magnitude of risk is comparable to – and in some cases even exceeds – other well-accepted risk factors such as smoking (up to 15 cigarettes a day), obesity, lack of physical exercise and high blood pressure. Loneliness has also been associated with increased emergency admissions to a hospital, longer length of stays, and delayed discharges. In fact, a November 2017 study concluded that the lack of social contacts among older adults is associated with an estimated annual increase in Medicare spending of $6.7 billion. One Can Be the Loneliest Number, But it Doesn’t Have to Be Greg Bishop, an attorney in Park City, suggests that retirement is a great opportunity to develop the types of connections that can prevent or alleviate the health consequences of living alone, being socially isolated, or feeling lonely. He notes that although there is a general consensus about the potential problem areas, the solutions are more elusive. He explains that although living alone and being socially isolated are determined objectively, the underlying causes are overtly personal. For example, living alone may be the result of the death of a partner or because of a recent divorce, whereas being socially isolated may arise from relocating after retirement or from the children moving away. Given that the underlying causes vary drastically, the solutions for living alone, being socially isolated, and feeling lonely will also differ. In short, there is no one-size-fits-all solution to these issues. That said, older adults will likely benefit from the following suggestions: Proactively stay involved in the lives of your family and friends. Find meaningful ways to connect with them via video chats, phone calls, text messages and letters Establish new social connections – go to the gym, take a dance class, learn to play chess, or join a book club Establish a more meaningful relationship with a church or social groups Look for opportunities to help and serve others. Fred Rogers – the television icon from Mister Roger’s Neighborhood – shared that when he was a boy and saw scary things on the television news, his mother told him to “Look for the helpers. You will always find people who are helping.” While that advice comforted him as a child, perhaps better advice for older adults dealing with social isolation and loneliness would be to “Look to be a helper. There are always people who are in need of help.” Read Also: Why Do You Need a Queens Personal Injury Attorney 6 Signs That You Need To Hire a Personal Injury Attorney Don’t Battle It All Alone: 5 Reasons Why You Need an Adoption Attorney These Four Qualities Are What You Should Be Looking For In Attorneys!  

Retirement Villages

5 Reasons Why Retirement Villages Are Good For You

Retirement can be a time of great change and uncertainty, and many people struggle to figure out the best way to spend their golden years. While some opt for traditional aging-in-place arrangements, others find that a retirement village offers a number of benefits that make it the ideal choice for their lifestyle. Here are five reasons why a retirement village might be the right choice for you. Community Living One of the most significant benefits of a retirement village is the sense of community that it provides. With like-minded individuals in a similar stage of life, you will have the opportunity to make new friends and engage in meaningful relationships. From social clubs and shared meals to recreational activities and organized events, there is always something happening in a retirement village. Safety and Security Many retirement villages offer round-the-clock security and peace of mind that you won't find in a traditional aging-in-place arrangement. With staff on hand 24/7, you can rest easy knowing that someone is always available to help in the event of an emergency. Some retirement villages also offer additional safety features such as emergency response systems, so you can stay safe and secure even if you live alone. Access to Amenities One of the biggest draws of a retirement village is the access to a wide range of amenities. From wellness centers and swimming pools to libraries and community gardens, you will have everything you need to enjoy your golden years. Additionally, many retirement villages offer transportation services, so you can easily get around and stay active even if you no longer drive. Maintenance-Free Living With a retirement village, you can say goodbye to the headaches and hassle of home maintenance. Many retirement villages offer all-inclusive living arrangements, taking care of everything from landscaping and snow removal to housekeeping and home repairs. This frees up your time and energy so that you can focus on the things you love, rather than worrying about the upkeep of your home. Affordable Living Finally, retirement villages are often more affordable than traditional aging-in-place arrangements. With lower overhead costs, a retirement village can provide you with a high-quality lifestyle at an affordable price. In addition, many retirement villages offer flexible financing options, so you can find the perfect arrangement to fit your budget. In conclusion, retirement villages offer a number of benefits that make them an attractive choice for many seniors. Whether you're looking for a sense of community, safety and security, access to amenities, maintenance-free living, or affordable living, a retirement village can provide the peace of mind and quality of life that you deserve. So why not consider a retirement village for your next chapter? Additional: What are Retirement Homes? Best Paying Jobs In Medical/Dental Instruments The Best Strategies for Retirement Funds Distribution 4 Fun Jobs After Retirement That Offer You a Monthly Income


Are You a Taurus? 8 Things to Know About Yourself

Are you Taurus? then What words come to mind when you think of a bull? Strength. Power. Intensity. Sublimity. All of the above!? Contemplating the character of this immense animal is a useful first step to understanding the qualities of a Taurus too: that illustrious second sign of the Zodiac that bears the symbol of a bull. Here are some quick facts for you. Taurus's are born between April 20th and May 20th. Their element is Earth. Their planet is Venus. Their lucky gem is an emerald. But what does that all mean for you? What are the specific Taurus traits that might shed some light on you and your personality? Let us help! Keep reading to find out the 8 key traits of this particular star sign. 1. You're Independent: Any Taurus-born is fiercely independent. Strong and resourceful, Taureans can walk through life confident in the knowledge that they have the qualities required to handle any challenges that arise along the way. Taurus doesn't need to rely on the support of others in such situations. They can quite happily navigate any obstacles alone. That said, they have strong social ties too. Their magnetism and strength of character draw valued friendships and bonds between loved ones. 2. You're Hardworking: Taureans are known for their hardworking characteristics too. Bulls symbolize work ethics, strength and power. All of these traits translate into an individual who strives to do their utmost to succeed in a task. Their resilience under pressure and willingness to achieve, all stacks up to create someone utterly committed to working hard. There's a reason we talk about 'grabbing the bull by the horns'. It speaks to initiative, perseverance and seizing the day. Through hook or crook, a bull will get you to where you need to go. 3. You're Dedicated: There's no going back once a Taurean decides on a particular path. We've already seen how you've got a hardworking nature. But it's possible to work hard for a short period of time, before quitting. That isn't in your character as a Taurus! Far from it. Think of a bulldozer. Why do you think it's called that? The image of this mechanical beast pushing, breaking and overcoming obstacles is the exact image that comes to mind when a Taurus gets its teeth stuck into a task. Simply, there's no stopping them. 4. You're Patient: Nothing will stop a Taurus from achieving what they set out to. This is partly to do with their dedication and commitment. But it's also thanks to the quiet patience that runs like a thread through their personality. A Taurus knows what they want and that one day they'll get it. And they're willing to both work hard and wait for the privilege of that achievement. Taureans are patient with people too though, and, for that matter, in almost all other aspects of life. 5. You're Sensual: Taurus is one of the most sensual of star signs. There's a hedonism to their pursuits, making sensory pleasure paramount. From touch, taste, sight, smell, and sound, Taureans place a high value on sensory gratification. There's an intensity to a Taurus. Beauty is big; satisfaction is sought-after. As you might expect, love-making is passionate and important (check out these tips on how to improve your sex-life). There's a tendency to fall hard for someone though, which can lead to challenges for the smitten Taurus. Without due care, the intensity behind their emotions can lead to a neediness that can harm the relationship. Sound familiar? Consider checking out your Taurus horoscope for clues on how to navigate the situation. 6. You Can Be Stubborn: Taureans have a reputation for being stubborn and bull-headed at times. Which makes sense, given the star-sign! Ever tried to get a bull to back down? It's no mean feat. It's the same with a Taurus. However, there's a fine line between stubbornness and extreme commitment. Some might argue they're two sides of the same coin. That's definitely the case with a Taurus. You're extremely committed, but that can easily be misconstrued as stubbornness. 7. You Can Be Lazy: You might be wondering how someone can be hardworking and lazy at the same time. It's a fair question! But Taureans pull it off adeptly. Again, think about a bull. Can you imagine trying to get a bull to do something it doesn't want to? Conversely, with the bit between the teeth, try stopping them from getting what they want! A Taurus creates their own destiny. They're utterly dedicated and committed to their own endeavors and they'll do whatever it takes to succeed. The issue comes when someone else's needs enter the equation. Operating under authority can be a challenge. It's difficult to persuade these zodiacal bulls to behave in the sole interest of others. It isn't malicious. It's simply a conflict of interests between the needs of self and other. 8. You Can Be Indulgent: A Taurus' independence and hardworking nature often lead to the ability to earn a lot of money and be self-sufficient. Think of it as the antidote to your hardworking nature. There's a hedonistic side to you. It feels good to indulge in decadence and material pleasures. You're prone to treating yourself. From long spa days and lust-filled encounters to eating rich, beautiful foods and so on, you like to feel satisfied. Do You Possess These Taurus Traits? There you have it: 8 Taurus traits to help you understand you and your star sign. A Taurus is an intense individual with a life characterized by extremes. Your positive qualities far outweigh the negative though. You're hardworking, dedicated, sensual, patient and independent. You're high achieving and exceptionally popular to be around as a result. Your internal drive can make you stubborn though. Your commitment to your own goals can make you seem lazy to others as well. And your hedonistic desires can lead you to overindulge at times. However you walk through life, you can be sure of having an adventure! Hopefully, the information here will have helped you understand yourself a little better. We'd love to hear about it if so! Can you see these traits reflected in who you are? Which one do you relate to most strongly? Let us know in the comments!