What is Upcoding?

Upcoding is when medical coders fraudulently charge medical bills. It is a criminal act that can cost patients and insurance companies thousands of dollars.

How it works is the supplier bills a health care coverage payer (regardless of whether private, Medicaid or Medicare) using a CPT code for a more costly service than what was performed on the patient.

The Truth about Upcoding

Upcoding is most certainly illegal, but that doesn’t stop people from trying to find ways to take advantage of the system. Providers that are attempting to cheat the system will use upcoding to pad their receivables beyond what they are rightly due from payers.

For individual patients and for taxpayers, upcoding is incredibly costly, as you can imagine. When it comes to patients, it can have a negative impact on their medical records. This process will put false information in their records, which will later influence the quality and amount of protection they are able to get in the future.

How Upcoding Works

Every surgery or procedure performed by a medical professional has a code attached to it. This code, called the CPT code (Current Procedural Terminology), allows them to charge Medicare, Medicaid, insurance or even the patient themselves.

At the point when any medical professional sends a code to the patient or their insurance, the CPT code decides the amount the patient or insurance will be charged and the amount the doctor will be paid. Each code relates to a different procedure with a higher or lower price tag. For whatever length of time that the doctor utilizes the right code, the doctor is paid according to the type of procedure performed.

With upcoding, the CPT code used will be one for a procedure that is more costly than what was actually performed.

How to Spot Upcoding

Say you visit your specialist for a quick visit. The code for this visit might say that your specialist should be paid $80. Be that as it may, the specialist who is upcoding may use a CPT code for an extended examination, which will allow them to be paid $200.

Upcoding is unfortunately a very real problem. The best way to avoid this is to carefully choose which medical professionals you interact with and keep your eye on the costs of your procedures.

If you are interested in outsourcing your medical billing, you need to work with a billing company you can trust. Always be sure to vet them first and to ask the right questions.

man looking at medical bills

Solving Transparency in Healthcare

Dread from a doctor’s visit comes twofold: there’s the actual appointment, and then there’s the mystery when receiving the bill. In both cases, the patient has hardly any idea what to expect.
lady drinking water

Ingestible Sensors – What Are They?

Sensors have taken their hold in the medical world. You see them mostly in the form of wearable technology, like FitBits, but can also come as apps and other forms of big data analytics.

5 Benefits of Outsourcing Medical Billing

Like any healthcare provider, you want to improve the bottom line for your practice. For most, though, billing is unfortunately a huge source of anxiety, both in terms of time spent and unpaid reimbursements.


Tips to Ensure Your Medical Practice Gets Paid

It’s unfortunate, to say the least, that health care providers have instances where they don’t get paid for their work, due mostly to the fickle nature of insurance companies. This doesn’t happen in most other industries.

The reality is, getting reimbursements from insurance companies is not easy. A late payment can cause many subsequent issues for your practice, and a denial can cost you tons. Unfortunately, late or non-payments can happen from your patients as well.

The Common Pitfalls of On-Time Payment

Getting both your patients and insurance companies to pay in a timely manner is often delayed by common issues. You may have seen these before:

    • Misunderstood billing procedures

    • Improperly functioning billing systems

    • Inability of patients to meet co-pay or deductible requirements

    • Accounts receivable is not routinely or expertly worked

    • Incorrect coding

    • Faulty documentation

Of course there are many other causes for late or non-payments, these are just a few. However, knowing the most basic problems might help streamline cash flow at your practice. Without knowing how to stop the financial hemorrhaging, your office bills can get behind quickly and thus reduce the overall revenue of your practice.

Better Ways to Get Paid on Time

In some cases, it just takes some time to make sure insurance companies and other corporate entities deliver reimbursements. Wouldn’t it be nice, though, to receive them as fast as possible? Here are a few techniques for doing so:

1. Use the Right Code

ICD-10 regulations are now in effect. Make sure your office equipment, software, and EHR are all up to date with the recent changes, or else you could face unnecessary stress in receiving reimbursements. It will also be necessary to train your existing staff on the updates to ensure proper compliance.

2. Keep an Eye on the Details

If everyone in your office has access to the same information, things in the billing department can run a lot smoother. Sometimes details get scattered, or communication is not consistent. If everyone can quickly review data and generate reports, it may cut back on the internal issues that cause denials.

3. Review Patient Benefits Ahead of Time

Before accepting an appointment, be sure to verify the patient’s insurance credentials. Early communication is key – you can inform potential patients of any co-pay they will be responsible for, so they know their costs ahead of time. For further protection, you can ask them to sign a document stating they will pay the bill by a certain date.

Again, these are just a few of the possible reasons for delayed payments. If you have other issues that are causing late payments, or missing them altogether, then contact us and we can discuss some resolutions for you.

Practice Management

  • Anesthesia Billing
  • Full-service medical billing
  • Patient account management
  • Encounter form design
  • Patient balance collections
  • Learn More

Practice Management

  • Anesthesia Billing
  • Full-service medical billing
  • Patient account management
  • Encounter form design
  • Patient balance collections
  • Learn More


MBA Medical Billing Services, Inc.
P.O. Box 821350
Vancouver, WA 98682

866-622-2455 Toll-free
360-687-5221 Vancouver, WA

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