Upcoding and the Law

Law Pertaining to Upcoding	Explanation of Upcoding	Case Example of Upcoding
18 U.S.C. § 1347- The criminal healthcare fraud statute. This statute makes healthcare fraud, such as upcoding, a criminal offense. This statute imposes hefty punishment for the crime.	Upcoding is when a provider assigns an incorrect billing code to a medical procedure or treatment to increase reimbursement. Medicare abuse exposes providers to criminal and civil liability. Furthermore, the program integrity comprises a range of activities targeting various causes of improper payments.	An example of upcoding is when a physician provides a follow-up office visit or follow-up inpatient consultation but bills a higher level E&M code as if they had provided a comprehensive new patient office visit or an initial inpatient consultation.

Law Pertaining to Upcoding

Explanation of Upcoding

Case Example of Upcoding

18 U.S.C. § 1347- The criminal healthcare fraud statute. This statute makes healthcare fraud, such as upcoding, a criminal offense. This statute imposes hefty punishment for the crime.

Upcoding is when a provider assigns an incorrect billing code to a medical procedure or treatment to increase reimbursement. Medicare abuse exposes providers to criminal and civil liability. Furthermore, the program integrity comprises a range of activities targeting various causes of improper payments.

An example of upcoding is when a physician provides a follow-up office visit or follow-up inpatient consultation but bills a higher level E&M code as if they had provided a comprehensive new patient office visit or an initial inpatient consultation.

Evidence-Based Recommendations to Address Upcoding

Recommendation*	Source
It is recommended that the best option and the only way to identify an Upcoding impasse is to collect and compare data on the E/M coding and billing. It is best to begin by aggregating all of the data for a given period, for instance, starting with data for the past few months from the system into a report, provider by provider.	(Bastani et al., 2019)
In detecting Upcoding or down coding, an individual must be conversant with the billing or fee schedule and be able to compare those to the amount mentioned on the E/M or the E.O.B. forms. In addition, the person must be familiar with the NCCI edits and mutually exclusive elements.	(Cook & Averett, 2020).
It is an issue of individual integrity; thus, individuals must make it a personal duty to ensure patient information is correct and aligned adequately with data and avoid Upcoding.	(Mackey et al ., 2020)
It is also recommended to utilize the current Medical coding manual to avoid billing duplication. In addition, there is a need to verify insurance benefits and coverage in Advance.	(Teng et al., 2020)
If an individual is not knowledgeable about how health billing is done, it is recommended that the entity or individual hire a professional medical biller. We also recommend Improvement medical billing and coding systems with Coronis Health.	(Sonawala, 2019).

References

Bastani, H., Goh, J., & Bayati, M. (2019). Evidence of Upcoding in pay-for-performance programs. Management Science, 65(3), 1042-1060. https://doi.org/10.1287/mnsc.2017.2996

Cook, A., & Averett, S. (2020). Do hospitals respond to changing incentive structures? Evidence from Medicare’s 2007 DRG restructuring. Journal of Health Economics, 73, 102319. https://doi.org/10.1016/j.jhealeco.2020.102319

Elsayed, D. E. M. (2020). Fraud and misconduct in publishing medical research. Sudan Journal of Medical Sciences (SJMS). https://doi.org/10.18502/sjms.v15i2.6693