While our country continues to deal with the COVID-19 pandemic, instances of fraudulent upcoding may be on the rise.
Upcoding is the fraudulent practice of billing medical services as more expensive than the service warrants. This can be done for, essentially, any medical service including patient diagnosis.
For example a medical provider could bill a service as being more complex or longer in duration than it truly was. This type of health care fraud has a significant impact on government funded health care programs like Medicare and Medicaid.
There could be several reason for the upcoding. Some may result for providers fraudulent seeking higher payment, while other instances may be the result of inadequate training. When insurance companies train front office staff, they are often train to search through doctor’s notes and find codes that the medical professionals may have missed.
There are tools to address fraudulent upcoding, including the False Claims Act. The federal government and several states allow for a whistleblower—known as the relator—to bring a civil action on behalf of the government. The Act affords whistleblowers important protections against retaliation, and allows them to share in any monetary recovery.