What is Upcoding?

Upcoding is a form of billing fraud where healthcare service providers submit false billing codes to obtain higher reimbursement at the expense of programs like Medicare, Medicaid, and TRICARE. Healthcare providers can upcode by making a false diagnosis for a more serious condition, exaggerating the amount of time they spent with patients, or billing for more expensive procedures than they provided.

An example of Upcoding is when a hospital or a healthcare facility carries out a surgery where the patient needs to be treated for a wrist fracture. But instead of the protocol, the severity of the injury is exaggerated to conduct unnecessary services and consequently increase the bills which are reimbursed by government healthcare programs.

what is upcoding in healthcare?

Unbundling vs Upcoding

Like upcoding, unbundling is a coding fraud that results in higher reimbursement. Many medical services are “bundled” together so that the healthcare provider receives only one lump sum payment for related procedures under one billing code. By splitting up these services into different codes, healthcare providers can illegally obtain duplicative payments from the government.

An example of Upcoding is when a hospital exaggerates the severity of a Medicare beneficiary’s wrist injury to justify a surgery that would normally be unnecessary. The hospital would therefore be able to receive larger reimbursements from Medicare. Another example is when a doctor falsifies the patient’s diagnoses underlying an office visit. If a patient comes in for just a sore throat but the doctor identifies more serious conditions like Streptococcus or even the COVID-19 virus as the primary diagnosis, this may be a sign of upcoding. The upcoding may also lead to other, unnecessary medical services, such as tests and screenings for the unsupported diagnoses.

Reporting Upcoding in Healthcare the Right Way

Whistleblowers with information about fraud in the workplace have over the years helped the government recover billions of dollars by reporting misconduct like Upcoding.

Healthcare professionals and administrative staff should report upcoding and unbundling under the False Claims Act to protect the integrity of the healthcare system and save taxpayer money. False Claim Act whistleblowers who retain experienced whistleblower attorneys stand to receive 10% to 30% of the total amount that the government recovers. Potentially millions of dollars could reward whistleblowers who want to do the right thing, the right way. Reach us at (877) 561-0000.