Everything to Know About Upcoding In Medical Billing

Medical billing and coding are intricate and complex. Entering the wrong diagnostic code may end up in overbilling the patients and your practice may face serious troubles. Often, common medical billing errors such as upcoding may be a result of an oversight error rather than an intentional mistake. Yet, the consequences can tarnish your practice’s reputation and expose you to expensive lawsuits.

This blog discusses upcoding, one of the common challenges in medical billing, and ways to prevent it in your healthcare practice.

What is Upcoding in Medical Billing?

Upcoding in medical billing is a fraudulent activity in which a bill sent for a healthcare service is more expensive than the service that was performed. In simple words, upcoding is a criminal offense where a healthcare provider bills a payer, whether private, Medicaid, or Medicare, using a CPT (Current Procedural Terminology) for a more costly procedure than what was performed at the time of treatment.

Healthcare providers use codes to identify healthcare procedures they provide to patients. Each code is billed to a particular service or treatment that patients may render as a part of their treatment. While some medical practices may upcode intentionally to reap thousands or even millions of dollars, sometimes they may be unaware that their billing staff is conducting this malicious activity.

Medical coding is an essential part of the healthcare billing system, and if it’s not done accurately as per the rules and regulations, it may slow down the reimbursement, leading to revenue loss. and expose your practice to compliance risks.

How Does Upcoding Affect Medical Practices?

Prevents Reimbursement

Upcoding can have a direct impact on your revenue. An inaccuracy in coding can negatively impact your revenue stream, resulting in reimbursement delays or denials.

Reduces Patients’ Experience & Trust

If patients suspect that the healthcare organization they got their treatment from is carrying out fraudulent activities like upcoding, they will never approach that healthcare facility for future treatments.

Reputational Loss

Once a patient realizes he or she has billed a large amount for a procedure they didn’t receive, it will straightway be considered a fraud and scam. Therefore, resulting in your healthcare facility’s reputational loss.

How Can Your Practice Prevent Upcoding?

Hire Professionals

Billing professionals and certified coders can help prevent upcoding mistakes in your medical billing process. They have the experience and skill set to quickly identify billing mistakes and streamline your billing process, ensuring your practice is strictly following the guidelines.

Conduct regular training

If your healthcare practice has an in-house billing team, it is advisable your team undergoes regular training to stay up-to-date with the current coding, compliance guidelines, and regulatory requirements. This step can prevent all types of medical billing and coding errors in addition to upcoding.

Use Accurate Tools & Software

For healthcare providers who handle their medical billing in-house, it is essential to use the right tools that can help detect an upcoding error and improve their billing process. So, make sure your system is equipped with the latest billing tools and software to make your medical billing process more efficient.

Establish internal procedures

Implement strict and accurate procedures for reviewing bills before posting them in the billing software. Have an in-house team to specially review bills thoroughly against each medical record to detect any errors.

Capline Healthcare Management is a leading medical billing and revenue cycle management company in the United States. We help clients establish the best practices for medical billing and coding. If you are a healthcare provider concerned about upcoding errors, contact our team of experts, who will help in developing processes to minimize the risks.