Upcoding fraud typically occurs when a medical provider bills for a higher cost procedure or test than was actually performed, taking more payment than was allowed given what the provider actually performed. Coding itself refers to the codes which are inputted by medical professionals to determine how much a medical provider should pay them for the coded procedure or test, for example.
By upcoding, the medical professional essentially tells the medical provider that a more expensive action was made; demanding a greater payout than otherwise would be had. Both federal and Florida law include heavy fines and severe criminal penalties, including potential mandatory/minimum sentences of up to 25 years and maximum potential sentences of up to LIFE. Mr. Petruzzi has represented numerous individuals charged with, or under investigation for, upcoding fraud offenses by both federal and state authorities. His experience and knowledge serve as an invaluable asset to his clients.
Federal upcoding fraud offenses are investigated and prosecuted by various agencies, including the FBI, IRS, and the Department of Justice. Some common federal statutes criminalizing upcoding fraud include:
18 USC Sec. 1347 –
(a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice –
(1) to defraud any health care benefit program; or
(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.
(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.
Florida upcoding fraud offenses are investigated and prosecuted by various state and local law enforcement agencies. Some common Florida statutes criminalizing upcoding fraud include:
817.50 Fraudulently obtaining goods, services, etc., from a health care provider.—
(1) Whoever shall, willfully and with intent to defraud, obtain or attempt to obtain goods, products, merchandise, or services from any health care provider in this state, as defined in s. 641.19(14), commits a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.
(2) If any person gives to any health care provider in this state a false or fictitious name or a false or fictitious address or assigns to any health care provider the proceeds of any health maintenance contract or insurance contract, then knowing that such contract is no longer in force, is invalid, or is void for any reason, such action shall be prima facie evidence of the intent of such person to defraud the health care provider. However, this subsection does not apply to investigative actions taken by law enforcement officers for law enforcement purposes in the course of their official duties.
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