“Upcoding” nets possible prison term for doctor

by • July 1, 2008 • UncategorizedComments Off on “Upcoding” nets possible prison term for doctor1626

• The Gist: Coding and billing fraud cases are becoming more common as the government seeks to crack down on reimbursement overpayments.

© 2008 The Medical-Legal News

A West Virginia physician was convicted by a jury in mid-June of 29 counts of fraud for billing insurers for services he did not perform, according to the Charleston Daily Mail.
Dr. John C. Sharp, 67, was found guilty of “upcoding” and could face up to 10 years in prison and a $250,000 fine on each count, or $7.25 million.
The prosecution accused Sharp of bilking Medicare, Medicaid, and worker’s comp out of $570,000 over an eight-year period.
Because of the large number of medical records involved, reviewers did a random sampling, according to The Pocahontas Times. The defense argued that such samples are not absolute. The defense also countered that some upcoding may have come from staff’s clerical errors, and that Sharp’s patients were especially sick and elderly, so as to put his extra charges for them outside normal reimbursement parameters, thus making him a legitimate “outlier.”
The prosecution noted that Sharp billed for office visits at too-high rates, billed for prolonged services, billed for office visits he did not do and had been audited on three previous occasions and told each time to correct the problems, according to The Times. 

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