Upcoding In Medical Billing: Never Try This!

By Author: Hannah Parker
Total Articles: 42
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What is the Relationship between Billing Codes & Upcoding?

As per the American Medical Association (AMA), each diagnostic test, office visit, or medical procedure performed by a medical practitioner has a corresponding Current Procedural Terminology (CPT) code.

When a patient visits your hospital for a healthcare service, your billing team sends a bill to the insurance payer. This bill contains the Current Procedural Terminology code corresponding to the procedure or different medical services done with lower or higher costs. The CPT codes all have their corresponding costs mentioned next to them. Though the CPT code does not translate directly to the payment, you must still claim the accurate bills with the correct CPT codes for the reimbursement.

How Upcoding Happens?

When a hospital uses upcoding practice, this indicates that the medical billers have assigned a code for a more expensive service than what was rendered to the patients.

For instance, you may have done a simple X-ray but have billed a more complex X-ray, including more views than what was done originally. Or, simple sedation ...
... may be billed as more complex anesthesia, or when a procedure was performed by a nurse, it may be billed as if it was performed by a doctor. In all such situations, upcoding arises.

Why Upcoding Happens?

Although upcoding is unethical and illegal, there are still numerous hospitals and medical care providers who have been caught doing this unethical practice. Administrators running the hospitals enjoy numerous benefits professionally from the impressive profits, and upcoding is one such way that is made possible by simply cheating the system.

In fact, certain medical practices are reaping hundreds of thousands or millions of dollars by upcoding fraudulently. Sometimes, even the nurses, doctors, and advanced healthcare practitioners are unaware of their services being up coded if malicious administrators upcode the medical billing secretively.

What are the Consequences of Upcoding?

The most substantial effect of upcoding is an increased cost to the health insurance payers- which they inevitably pass on to their consumers.

When the government insurance payers end up paying excessive amounts for healthcare, it gets reflected in the government budget and taxes. And, when the healthcare insurance companies overpay due to upcoding, they pass on the cost of overpayment to their consumers in terms of premiums as a way to offset the monetary loss faced by them.

What to Do – If you Suspect Upcoding (As a Patient)?

As a patient or otherwise, if you suspect that the hospital from where you got your treatment done is guilty of upcoding, there are some actions that you should take to ensure that your payer is not getting billed fraudulently. You can initiate by checking your Estimate of Benefits (EOB) to double-check the services your payer has been billed for and whether they match up to the services you received.

In case a problem is suspected with your bill, you can take the following series of steps:

First, get in touch with your healthcare provider and ask them directly about it. They might be able to explain to you why they have billed so and why it is correct, or they might offer to get it corrected. Or they might also be just as disturbed by the discrepancy as you are.
You have to keep in mind that your doctor is not in charge of billing you for the referred service. If you have been referred to a lab or a diagnostic facility and they have billed you incorrectly, you must let your doctor know so that they can stop referring to those labs or diagnostic centers.
You can also consider calling the diagnostic facility or the lab to see if they can provide you with a reasonable explanation for the upcoded bill.
If you notice a discrepancy in your EOB and suspect any foul play, you can also inform your healthcare payer about the same.
If your payer is a private company, then prefer calling their customer care service and ask them to whom you should report the upcoding fraud.
If you receive Medicaid, you have to check in with your state’s Medicaid office to see how they report the fraud.
If your payer is Medicare, check the Medicare website for the details and other steps to report an upcoding fraud.
A Word from Info Hub!

Unfortunately, a lot of hospitals, healthcare providers, and diagnostic facilities are often caught for upcoding. And, this can, of course, result in huge penalties for the healthcare administrators and even jail at times. However, certain medical billers are skilled at such illegal and unethical activities and can hide their misdeeds behind the systemic malfunctions or bureaucracy to avoid getting blamed for the issue. Therefore, the best decision in such a circumstance is to assign billing duties to professionals like Info Hub, who are far away from such fraudulent practices.

Upcoding is a fraudulent technique used by a lot of healthcare providers & medical billing companies to claim more dollars. Read more about the disadvantages of Upcoding in this article