According to Black Book Research’s data, 90% of medical coders and health information management professionals who participated in the survey agree that the practice of upcoding remains a key ethical predicament for medical coding and billing experts.
Upcoding is when medical providers assign inaccurate billing codes to justify higher payments. This could involve the exaggeration of the nature of a patient’s condition in a hospital setting to delay discharge, splitting one test into two or reporting symptoms that are not present to secure a test. This manipulation of the billing system is unethical and could impact patients’ lives negatively as well as tarnish the reputation of healthcare providers in general.
Let’s dig deeper into upcoding, its impact on patients, and the steps to detect and address it within the healthcare system.
The Basics of Upcoding
As mentioned, upcoding occurs when a healthcare provider uses a billing code that doesn’t accurately reflect the services provided. This deceptive tactic can lead to increased reimbursement from insurance companies or government programs.
Financial crime lawyer Jonathan Savella says upcoding is one form of healthcare fraud and this action is intended to exploit the healthcare system. Upcoding also targets various entities and private insurance companies. Healthcare fraud is a serious matter warranting severe penalties.
Patients are often unaware of upcoding since it’s done behind the scenes and aside from the highest cost for payers, upcoding can also lead to unnecessary treatment or procedures for patients. As a patient, review your medical bills carefully and don’t hesitate to ask questions if you notice any discrepancies.
Healthcare providers must also ensure they’re using the correct codes that accurately reflect the services rendered.
Common Types of Upcoding
There are common types of upcoding practices that healthcare providers may engage in. One common type of upcoding is known as code unbundling, where separate procedures that should be billed together under one code are instead billed individually to increase reimbursement.
Another practice is code inflation, where a provider may use a higher code than what’s justified by the services provided, leading to higher payments.
Upcoding can also involve billing for services that weren’t actually performed, such as charging for a more complex office visit than what actually took place. Some providers may upcode by using diagnosis codes that suggest a more severe illness or condition than what the patient actually has, resulting in higher payments.
Impact on Patients
Upcoding can have significant negative impacts on patients’ financial well-being and access to appropriate healthcare services. When healthcare providers engage in upcoding practices, patients may face higher out-of-pocket costs due to inflated bills. This can lead to financial strain, making it difficult for patients to afford necessary medical treatment or prescriptions.
Upcoding can also result in patients receiving improper care or unnecessary procedures. If a patient is billed for a more severe condition or a more complex procedure than what was actually provided, it may lead to delays in receiving the appropriate treatment.
This not only affects the patient’s health outcomes but also wastes valuable time and resources.
Consequences for Providers
From a legal standpoint, providers engaging in upcoding practices may face charges of healthcare fraud, which can lead to severe penalties including huge fines, exclusion from participation in federal healthcare programs, and even imprisonment. As mentioned, legal consequences can tarnish a provider’s reputation and have long-lasting effects on their ability to practice medicine.
The implications of upcoding go beyond just monetary losses; they can also damage relationships with other healthcare professionals and institutions, impacting future career opportunities and collaborations.
How to Detect Upcoding
Detecting upcoding practices can help ensure accurate billing and protect against fraudulent activities. Always look for discrepancies, such as billing for services not performed, using higher-level service codes without proper documentation, or billing for more complex procedures than what was actually conducted.
If you have been receiving treatment for some time, you may have the chance to analyze billing patterns over time. Keep an eye out for sudden increments in billing for certain procedures or services, especially if there’s no valid explanation for the increase in volume.
Conducting regular audits of medical billing records can also help identify any inconsistencies or irregularities that could indicate upcoding practices.
Conclusion
Upcoding undermines patients’ trust in the healthcare system and compromises their ability to receive the quality care they deserve. If you suspect upcoding, don’t hesitate to speak up and report it to the appropriate authorities
