What is upcoding?

Upcoding is a type of healthcare fraud that occurs when a healthcare provider bills for a more expensive medical service or procedure than what was actually provided. This can involve billing for a higher level of service than was necessary, using a more expensive code for a service than was justified, or billing for a service that was not actually performed. 

Upcoding can occur in various settings, including:

  • Hospitals
  • Clinics
  • Nursing homes
  • Home health agencies
  • Urgent care facilities
  • Other healthcare settings

Upcoding or medical billing fraud is a form of healthcare fraud that is illegal under federal and state laws.

At Newman & Shapiro, we specialize in representing whistleblowers in healthcare fraud cases, and we have a long track record of recovering multi-million dollar settlements on behalf of our whistleblower clients. 

Get in touch today for a free confidential assessment of whether you might have a potential upcoding or provider billing fraud lawsuit that could result in a whistleblower award:

How does upcoding work?

In the healthcare industry, medical services and procedures are assigned codes that are used for billing purposes. These codes are based on the Current Procedural Terminology (CPT) system, which is a standardized system developed by the American Medical Association for describing medical, surgical, and diagnostic services. 

Each CPT code corresponds to a specific service or procedure and has a corresponding reimbursement rate.

Upcoding occurs when a healthcare provider submits codes that are intentionally incorrect for a given service or procedure, in order to receive higher reimbursement from an insurer or federal healthcare programs like Medicare or Medicaid services. 

Upcoding is a form of healthcare fraud, Medicare fraud or Medicaid fraud.

stethoscope, medical, health

Examples of Upcoding and Provider Billing Fraud

Dishonest individuals and companies working in the healthcare field have devised numerous strategies for committing billing fraud against federal healthcare programs. 

Some of those methods include:

  • Billing for services and supplies that were never rendered to the patient;
  • Billing for medically unnecessary procedures;
  • Billing for more expensive treatments or medical procedures than actually provided;
  • Billing for services provided by unsupervised mid-level providers as if those services were provided by a physician (incident-to billing); 
  • Billing for services provided by unlicensed clinicians who were not adequately supervised; 
  • Billing for a more expensive diagnostic test than was performed;
  • Billing for a more expensive medication than was actually prescribed; and
  • Billing more time for a visit than it actually took and submitting incorrect Evaluation and Management codes (E&M) codes.

Who can be a whistleblower for upcoding issues?

Providers, nurses, therapists, billers, facility staff, or even patients (including Medicare patients and Medicaid patients) who observe improper billing practices can report upcoding by filing a False Claims Act case. 

Role of Whistleblowers in Exposing Upcoding and Other Forms of Healthcare Fraud

Whistleblowers play a critical role in exposing upcoding and other forms of healthcare fraud. 

Healthcare whistleblowers are courageous individuals who report evidence of illegal or unethical activity by a healthcare company. In the case of upcoding, whistleblowers may be doctors, nurses, other healthcare providers, office staff or other employees, or even patients who have knowledge of the fraudulent activity.

In the United States, the False Claims Act is a federal law that allows individuals to bring a lawsuit on behalf of the federal government against individuals or organizations that have defrauded a government program, such as Medicare or Medicaid. Many states also have their own False Claim Act statutes.

This is often called a qui tam action.

Qui tam whistleblowers who bring a successful False Claims Act lawsuit may be entitled to a portion of the recovered funds, called a relator award.

Get in touch today for a free confidential assessment of whether you might have a potential qui tam lawsuit that could result in a whistleblower award: