Upcoding is a type of fraud that can occur in medical institutions. It is often associated with Medicaid fraud or Medicare fraud, but it can also arise in other types of health care fraud schemes.
Medical procedures are assigned specific billing codes. When seeking reimbursement, a medical provider submits these codes to indicate the type of treatment that was provided to the patient.
Upcoding occurs when a medical professional submits a code for a procedure that is more expensive than the one that was actually performed. By doing so, they seek a higher level of reimbursement than is typically allowed. This makes upcoding a form of financial fraud, as the reimbursement is obtained through deceptive means.
This is different than phantom billing
A related form of fraud is phantom billing, which occurs when a medical provider submits codes for services that were never provided at all.
Upcoding is different because the patient did receive treatment. The issue is that the treatment is being misrepresented. For example, a patient may have undergone a simple, noninvasive procedure, but the provider may submit a code for a more extensive surgery that required anesthesia. The provider is not falsely claiming that treatment occurred, but is misrepresenting the nature of the treatment to receive a higher reimbursement.
Whistleblower options
Many fraud cases are brought to the attention of authorities by whistleblowers who witness the misconduct firsthand. Whistleblowing is legal, but it can be intimidating for individuals to come forward. That is why it is important for whistleblowers to understand their legal rights and options at this time.