Upcoding, a Common Medical Fraud Exposed

Upcoding, a Common Medical Fraud Exposed


Upcoding is a fraudulent medical billing practice that takes various forms, but typically involves inflating the complexity or severity of a patient’s condition. By assigning higher billing codes or more severe diagnoses than warranted for the services rendered and/or the patient’s condition, billing departments obtain higher reimbursements from insurance companies or government programs such as Medicare or Medicaid.

By upcoding, these provider departments aim to maximize their revenue by charging higher rates for services that do not align with the actual care provided. Upcoding not only defrauds insurance companies and government programs, but also leads to increased healthcare costs for patients and taxpayers (i.e., higher insurance premiums) and the resultant decreased accessibility to affordable healthcare.

To combat upcoding, insurance companies and government agencies employ various strategies such as audits, data analysis, and software algorithms to identify suspicious billing patterns. However, due to the complex nature of healthcare, it is not possible to fully assess a claim without reviewing the clinical record.

Ethical medical billing practices are crucial for maintaining the integrity of the healthcare system and ensuring fair and affordable healthcare for all.

Learn more about the threat of upcoding and its substantial cost to US healthcare in our latest on-demand webinar, Upcoding, a common medical fraud exposed, in partnership with NHCAA.

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