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.