The Two big ‘NO’s in Revenue Cycle Management - Upcoding and Overbilling

What Is Upcoding and Overbilling?

Upcoding and Overbilling are unethical revenue cycle management practices committed knowingly or unknowingly by a healthcare service provider resulting in a higher reimbursement than the actual for the care provided to a patient. Irrespective of the intend, this is considered a serious compliance risk leading to a series of adverse effects to the provider including jail term.

Why providers should safeguard themselves from Upcoding and Overbilling?

Upcoding or Overbilling is considered a fraudulent business practice in Revenue Cycle Management. Once detected, whether intentional or unintentional, can lead to heavy penalties and even criminal prosecution.

What Is Upcoding and Overbilling?

When do Upcoding and Overbilling happens?

Upcoding and Overbilling occurs under various situations, all of which start mainly due to oversight & negligence. Inaccurate Coding is the main reason for Upcoding. It can also occur when you code for treatments that were not medically necessary for the patient.

Double Billing is the most common reason why Overbilling occurs. When you simply inflate the total amount your payer organization owes you on a bill, you are doing Overbilling. Unbundling or fragmenting billing codes is another major source of Overbilling. This happens when a coder illegally increases a provider's profits by billing bundled procedures separately, which results in higher reimbursement.

Top Six Causes of Up Coding & Over Billing

Top Six Reasons of Upcoding and Overbilling

  • Coding errors that result in higher bill amount than the actual
  • Unbundling or fragmenting billing codes which ideally could have billed in bundled form
  • Billing for services the patient did not need
  • Billing for services not provided to the patient
  • Billing for a more expensive service than what was actually provided
  • Double Billing

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