Upcoding in medical billing - A fraudulent practice you should be aware off

There are many laws in the United States pertaining to fair Healthcare practices. However, one of the recent fraudulent ways wherein an insurance company or even private insurer can be made to pay astonishing medical bills is Upcoding. For the unknown, Upcoding is deceitful medical billing and coding procedure that costs you money and perhaps health as well. It refers to a practice, in which a provider bills a payer, whether private, Medicaid or Medicare utilizing a CPT code for a more costly administration than what was performed.

Upcoding is unlawful. It's a false practice utilized by providers who are attempting to cheat the medical billing and coding framework in Ohio, Texas and different states of the country, as they will be paid more amount than what they have arranged with those payers. It is expensive for individual patients and for senior citizens, but if contacted with an outsourced billing agency can readily be stopped.

Further, upcoding can have negative health repercussions for patients. It puts false data on their restorative records, and can influence their future capacity to get insurance.

Details about Upcoding

Every procedure performed by a physician or in-house accounts department has a code connected to it that permits them to charge your insurance, Medicaid or Medicare, or whoever your payer is, which may even be you, the patient. That code is known as a CPT code, which stands for Current Procedural Terminology.

When your doctor sends the bill to your payer, that CPT code decides the amount he or she will be paid. Diverse codes relate to various procedures or benefits and can have higher or lower costs. For whatever length of time the supplier/provider utilizes the right code, then the supplier is paid based on the services performed.

However, when an insurance provider allots a code for a more costly administration or procedure than what was performed, upcoding fraud arises.

What can be done in case of Upcoding?

If you check your Explanation of Benefits (EOB) and think that the physician is blameworthy of upcoding, there are a few steps to check that and ensure one has not been charged deceitfully.

To begin with, contact your supplier and get some information about it. They can either disclose to you why it is right, or they may offer to omit and correct the coding errors. In either case, it will put you on notification that you have to keep checking your EOB every time one arrives.

If you aren't fulfilled by the answer, and regardless of the possibility that want to correct it, you'll need to check past EOBs to check if you can recognize a pattern in upcoding.

  • If you think your supplier/provider and not the outsourced medical billing agency is upcoding all the time, you'll need to report it to your payer immediately. If the insurance provider has upcoded your consideration more than once, then they must have done it to others, as well.
  • If the payer is a private insurance provider then call their client service center and ask to whom you ought to report the upcoding extortion.
  • If you get Medicaid, you'll have to check with your state's Medicaid office to perceive how they need upcoding or other unlawful healthcare fraud reported
  • If your payer is Medicare, you'll discover the progressions for reporting frauds, including upcoding, at the Medicare website.


Do remember that Upcoding can have a negative impact on your future care and consideration procedure and future ability to get health insurance, depending on the code the doctor uses. It's a wise decision to assign the duties of medical coding and billing to a professional firm as they are far-off from such a fraudulent coding technique.

Published By - Medical Billers and Coders
Published Date - Aug-29-2016 Back

Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes?



Looking for a Medical Billing Quote?

Are you looking for more than one billing quotes ?





Would You like to Increase Your Collections?