upcoding

upcoding

Medicare A fraudulent practice in which provider services are billed for higher CPT procedure codes than were actually performed, resulting in a higher payment by Medicare or 3rd-party payors. See Coding, CPT coding, Health care fraud, HIPPA Act, Prompt payment law, Rebundling, Unbundling. Cf Downcoding.
References in periodicals archive ?
This often includes inflated medical bills, charges for services not rendered and deceptive billing practices such as upcoding, unbundling or modifier abuse.
Other false claims and provider billing errors include unbundling, double billing, and upcoding.
Some physicians responded by upcoding --claiming greater complexity in patient encounters than was in fact the case--and fraud investigations at some centers were under way.
However, if providers are not diligent in reviewing the information that often is quickly pasted in, the feature can be a vehicle for introducing errors that could result in fraud charges and possible fines for upcoding, for example.
Upon taking the bait, physicians find themselves targeted by insurers, Medicare recovery audit contractors (RACs), and even prosecutors, who accuse them of fraudulent upcoding.
Those include an aggressive plan to compel more physicians forward to adopt EHRs, improving interoperability via the Blue Button Initiative and other means, and cracking down on potential "gaming of the system" through EHR-facilitated upcoding.
Physicians can be challenged for overbilling, underbilling, upcoding, using the wrong code, and the provision of care not deemed medically reasonable and necessary because it is more care than should have been provided, less care than
One of the most common examples of fraud is upcoding, where a medical provider bills the insurance provider for a similar but more expensive patient procedure to maximise payout.
But now the government is also warning providers not to abuse the technology by engaging in fraud through either improper upcoding or the cloning of medical records.
The Center for Public Integrity recently concluded a 21-month investigation into the higher Medicare billing that has emerged over the last decade, including upcoding through the use of EHRs.
Third, optimal coding of comorbid condition required in risk adjustment may have been gamed through upcoding, thus leading to observed outcomes that are better than predicted, he suggested.
Leap covers a variety of health care fraud crimes such as: kickbacks, illicit referrals, overcharging, upcoding, insurance scams, short-pilling, and more.