How to Resolve Upcoding Situations

Posted by KUNAL JAIN on May 12 2015

Upcoding SituationsAs a physician, you are aware of the many tough decisions you have to make in your career. Whether you have to conduct judgment calls on a patient with latent repercussions or let a staff member go in lieu of ethics, being a physician and upholding your Hippocratic Oath isn’t easy.

In a situation where upcoding or upcharging occurs, it is something that requires immediate attention. This not only compromises the physician, but it also risks ruining the reputability of your practice. In this situation, the adage “any publicity is good publicity,” does not apply.

Federal and state governments are cracking down on this in recent years, and don’t intend on abating. According to the American Association of Orthopaedic Surgeons (AAOS), this law allows the government to claim up to three times the damages, plus civil penalties of up to $10,000.00 per false claim.

Changing a CPT code in order to earn more reimbursement from your patient’s healthcare provider is fraudulent and threatens the quality of the patient’s future care as well as their health insurance rates. Imagine being rejected years later as a patient who changes jobs because their health insurance claims they have a pre-existing condition, when that isn’t truly the case.

There are ways to recognize and resolve these issues as you become aware of upcoding in your practice.

Recognizing the Issue

As physicians, taxpayers and premium holders (in which it’s now required that everyone have health insurance), mitigating these errors is essential to the quest of lowering healthcare costs. With upcoded bills, especially with Medicare, this raises premiums for everyone enrolled. That may not seem like a concern for those without Medicare, but keep in mind we all contribute and pay for Medicare.

  • Examine EOBs—if you have a third-party billing agency, check to see if medical services are on there that were not rendered to the patient. If so, the CPT codes may be being changed.

  • Talk to your coders if you do in-house billing—is anything consistently suspicious going through? Your staff may know more than you do and can shed some details on the situation.

Resolving Future Upcoding

While it’s important to recognize the signs, it’s even more important afterward to enforce preventive measures so it doesn’t happen again. You may have to take some drastic changes to ensure the future profitability and rapport of your practice remains on an upward scale and not the other way.

Some things you can do:

  • Look out for macros and/or automatic population in your EHR—these can encourage bad practices and have information not reviewed on the medical file. This places physicians and hospitals at legal risk in the event of an audit.  

  • Conduct regular billing audits. The AAOS endorses these audits in order to find discrepancies within your practice in order to correct them quickly and not allow them to accrue.

Key Takeaway

Coding for improper CPT codes for services not actually rendered is a serious and illegal offense in which physicians can be charged exorbitant civil penalties. Make sure you hire professional and efficient coders or third-party billing services that have good reputation for accuracy and integrity.

While electronic billing has been endorsed, this doesn’t mean you should be performing fraudulent activity with its features (knowingly or not). Conduct due diligence in researching which EHR has the best features to optimally perform and provide the most updated records and information processing for your practice—this will help in the quest to resolve any upcoding of codes that may threaten to appear.

So tell us in the comments below—what strategies have you implemented into your medical practice to prevent upcoding?


Topics: upcoding

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