Upcoding: a common practice that needs to end

What’s up(coding)? Let’s talk about a common practice that needs to end.

After you leave the doctor’s office, what happens to your chart?

It goes to a billing office, where someone trained in medical billing maximizes the revenue for that visit by ensuring the services performed are properly coded.

But many times they also:
• Increase the severity of billing codes
• Add additional codes the payer’s algorithm will accept

But here’s the catch: these enhanced or additional services often never happened.

It’s billing for a level-five office visit when you were only seen for pinkeye for three minutes.
(Here’s a chart to break it down: https://lnkd.in/emkiytjB)

Or adding a weight loss consultation to your visit because the algorithm will allow it—even though it wasn’t actually performed.
(Novo Nordisk’s coder handout teaches how to code, but doesn’t explicitly endorse fraud: https://lnkd.in/eqw6yQjZ)

In any other field, we’d call this fraud.
• A lawyer bills you 1.0 for a task that took 0.1? Fraud.
• A mechanic charges you for brakes they didn’t replace? Fraud.

But in healthcare? We call it “upcoding.”

Let’s be clear: this is not a hospital “winning.” It’s stealing—billing for procedures that never happened.
And when it targets Medicaid or Medicare? It’s a federal crime.

Here’s what needs to change:
• Stop “both-siding” this issue. The American Hospital Association doesn’t need equal airtime here like it’s a legitimate revenue issue.
• Ramp up prosecution. Use the False Claims Act for treble damages and penalties.
• Demand integrity. Pay people fairly for the value they add, but punish fraudsters.

Have you been the victim of upcoding? Were you able to fight back?

https://lnkd.in/erTDZcuM