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What’s The Difference Between Upcoding and Unbundling in Healthcare Fraud?

The Medicaid and Medicare programs use a set of billing codes that medical providers must use in order to submit government health care claims for the services that they have provided. Altering or manipulating the codes in order to maximize the government’s reimbursement is a form of health care fraud. If you are aware of this type of fraud being committed by your employer, you may be able to report it while serving as a whistleblower under the False Claims Act’s qui tam provision. The experienced qui tam lawyers at Swartz Swidler can advise you of whether or not you have valid grounds to file a qui tam action.

What Is Upcoding

One type of fraudulent medical billing practice that is commonly used in order to defraud the government is called upcoding. This happens when a health care provider uses a higher-paying code on a patient’s claim form in order to falsely claim that the provider performed a more costly procedure than what was actually performed. Medical providers who routinely engage in upcoding can pocket huge sums of fraudulently obtained money from the government. It is estimated that this type of Medicaid and Medicare fraud costs taxpayers billions every year.

Schedule an appointment today. Call (856) 685-7420 or

Schedule an appointment today.
Call (856) 685-7420 or

What Is Unbundling

Another common, fraudulent medical billing practice is unbundling. This is often found in laboratory billing. Unbundling occurs when a provider bills for services individually instead of submitting them at a bundled rate. Submitting the services on a piecemeal basis is done to maximize the amount of money that the provider can receive in reimbursements. Medicaid and Medicare rules require some procedures and tests to be billed together at a lower total bundled rate.

Clinical laboratories are often the sites of unbundling. Doctors frequently order certain panels of tests to be performed as groups, so separate codes have been developed for these specific panels. However, there are also codes for the individual tests. This means that the laboratory may receive greater reimbursements when they bill the individual tests separately rather than billing for the panels that were ordered.

Contact the legal team at Swartz Swidler

If you have knowledge of Medicaid or Medicare billing fraud at your job, it is important for you to talk to the legal team at Swartz Swidler. To learn more about your rights, fill out our contact form. We will return your call and talk to you about whether or not you have grounds to file a qui tam action.

Most Frequently Asked Question: Do I Have A Case?

While it is true that every case is different, The law is pretty clear in most cases. The best way to determine if you have a case is to contact one of our attorneys. For more information check out the FAQ below or visit our FAQ Page

Most Frequently Asked Question:
Do I Have A Case?

While it is true that every case is different, The law is pretty clear in most cases. The best way to determine if you have a case is contact one of our attorneys. For more information on a just a few scenarios checkout the flip box FAQ below or visit our FAQ Page.

Our Locations

Cherry Hill Headquarters

1101 Kings Hwy N
Suite 402
Cherry Hill, New Jersey 08034

Phone: (856) 685-7420
Fax: (856) 685-7417

Philadelphia Satellite Office

123 South 22nd Street
Philadelphia, PA 19107

Phone: (215) 995-2733

Our Locations

Cherry Hill Headquarters

1101 Kings Hwy N
Suite 402
Cherry Hill, New Jersey 08034

Phone: (856) 685-7420
Fax: (856) 685-7417

Philadelphia Satellite Office

123 South 22nd Street
Philadelphia, PA 19107

Phone: (215) 995-2733