The Downside of Upcoding

You might not think upcoding is an issue we should worry about, but research shows it affects the entire medical community. Upcoding refers to a provider manipulating CPT codes for higher reimbursement when billing an insurance carrier, whether private or government. Upcoding is illegal! It’s the fraudulent way shady providers try to cheat the system so they will be paid more money than they have negotiated with insurance companies for services they may or may not provide.  

Because upcoding commands more money than the correct code for service will actually pay, this kind of illegal activity costs everyone involved. Upcoding is a form of fraud and can come with nasty little accessory items such as charging too many services, sending too many bills, and altering or falsifying medical records. Physicians that have been caught breaking this law have paid millions in fines and lawsuits. Some have even gone to prison.

Physicians aren’t the only culprits of upcoding. The government also has held clinical laboratories liable when they induced physicians to order unnecessary add-on tests by including the extra test in a standard blood chemistry panel at minimal or no extra charge to the physician. The lab then bills Medicare for the additional test – sometimes without the doctor's knowledge – creating a higher profit for their facility.

This is all very costly for individual patients and taxpayers. Improper reimbursements have cost the United States billions of dollars in payments that were inappropriate due to lack of medical necessity, insufficient or no documentation, and/or incorrect coding. When a physician decides to falsify medical records for capital gain, it’s at the expense of the patient.

For example, suppose a patient has chest pain. Their provider may run an EKG and, while everything is normal and they leave relieved because they now know it was heartburn, their doctor bills for that EKG in addition to an appointment for a heart patient, which has a higher reimbursement rate. This kind of alteration in medical records now classifies the patient in the category of “problem patient with a medical condition.”

This may affect how the patient is treated for care in another medical facility since whoever is providing treatment may work around effective medications and seek alternatives that do not flare up the diagnosed “heart condition.” If the patient becomes unemployed and uninsured, it can affect not only getting another job but also the health benefits that may come with another position.

We all know how difficult it is to get needed coverage from an insurance company with a pre-existing condition. An insurance company will either refuse to provide coverage or make the premiums so high that only hitting the Power Ball jackpot will help pay for it. This leads so nicely into another point.

Whether you are the individual with the false heart condition or it is your neighbor, because of upcoding, we all pay the price because it affects premium rates. Think about it. Upcoding may cost us millions of dollars over time, with only one provider engaging in the misuse of CPT codes. A physician may bring in the money just during flu season, when patients visit a provider for flu symptoms. Perhaps the physician upcoded all the claims and charged each patient for an office visit and a diagnosis of bronchitis and sinusitis.

Checking out the explanation of benefits (EOB) can help the patient determine whether the doctor they have chosen for care is engaging in upcoding. When doing an audit regarding a physician or a facility, the auditor may request voluntary responses from patients who have received medical care and compare the patients’ responses to the codes on the EOB forms.

One audit showed a patient that claimed to visit a dermatologist for a routine skin cancer screening; the insurance company was billed for removing a cancerous growth. There are certain diagnosis codes that are on a watch list, and if an inspector receives a higher percentage of claims from a facility for those diagnosis codes, they'll go into a facility and conduct a full audit.

Patients should take a second look at their EOB and not hesitate to ask questions. Physicians should think carefully and be aware of their documentation. You should only be concerned with upcoding if that is what you are actually doing. If you are doing a level 5 office visit, then code a 99215. However, be certain you have the documentation to back up the medical treatment and coding. Do not shortchange yourself by coding a level 1 office visit if that visit is requiring so much more. Every physician is capable of providing proper care to the community without hurting their integrity and cheating the system. Upcoding is a serious offense that is hazardous to the health and wallet of patients, physicians, and taxpayers.  

Minerva DeJesus and Auriana (Audi) Reyes founded Simple Solution Billing, a nationwide medical billing company. They have a diverse medical background with more than 20 years of experience helping physicians control their finances while maintaining control of their practice. For more information on acquiring higher reimbursements for services rendered, contact SSB at simplesolutionbilling@yahoo.com. 

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