Marilyn has asked a great question…
if you have an appointment with a doctor and the tech takes your blood pressure and temp then tells you the doctor is not in. You wait and ask the tech one or two questions while waiting. The doctor does not show up. Should you be charged the full amount for the visit?
If Marilyn was charged for a 5-minute visit with a physician assistant or another type of medical support staff, she (or her insurance company) was correctly billed for the service she received. But if Marilyn was charged for a longer visit with a doctor – which costs more – she was overcharged.
There are two possible explanations for the overcharge: The doctor’s billing department…
- made an honest mistake.
- intentionally overcharged by upcoding, which is a form of fraud.
For the sake of this article, let’s assume the worst. But before you can learn how to prevent yourself from falling victim to this illegal practice, you need to understand what it is.
What is upcoding?
Upcoding is the medical industry’s term for a specific type of overcharging. It’s when a health care provider intentionally bills for more-expensive services than were actually provided (or, at hospitals, more-serious diagnoses than were actually treated), usually to receive a bigger reimbursement from the patient’s insurance company.
Here are three examples from the FBI, whose Health Care Fraud Unit investigates upcoding:
- A routine, follow-up doctor’s office visit being billed as an initial or comprehensive office visit
- Group therapy being billed as individual therapy
- 30-minute sessions being billed as 50+ minute sessions
This practice made national headlines in the 1990s, when many hospitals were accused of upcoding patient diagnoses. The worst offender, Columbia/HCA (now HCA), agreed to pay the U.S. $1.5 billion – yes, billion with a B – in fines, penalties, damages, and restitution. The Department of Justice called it the “largest health care fraud case in U.S. history.”
Today, upcoding is still a problem. Just last week, SCAN Health Plan paid a $327 million settlement after state and federal authorities investigated the HMO for overcharging California’s Medicaid program. California Watch reported it was “the largest-ever Medi-Cal overpayment settlement.”
Why is it called upcoding?
Up presumably refers to billing for a more-expensive service. Coding refers to how health care providers submit insurance claims, which you need to understand to be able to guard against upcoding.
Each type of medical service corresponds to what’s called a CPT code, which is a five-digit code in the Current Procedural Terminology, or CPT.
Think of the CPT like a dictionary – except instead of a long list of words and their definitions, it’s a long list of numbers (CPT codes) and their “definitions” (the corresponding medical services).
When I fractured my ankle, my orthopedist took a few X-rays. So he billed my insurance for a 73630, the CPT code defined as “radiologic examination, foot; complete, minimum of 3 views.”
The purpose of the CPT is to create a medical billing system that is uniform regardless of who provided the medical service and who gets billed for it. According to the American Medical Association, which maintains the CPT, it’s “the most widely accepted medical [naming system] used to report medical procedures and services under public and private health insurance programs.”
How can patients protect themselves from upcoding?
Compared to trying to understand upcoding, preventing it should be pretty straightforward…
1. Review your bills ASAP.
Just as you (hopefully) review your credit card bill and bank statement when they arrive, you should scrutinize every medical bill and statement (also known as a summary or explanation of benefits) when it arrives. The goal is to understand exactly what the health care provider billed for.
If the bill includes CPT codes, look up their “definitions,” which patients can do using the American Medical Association’s free CPT Code Search tool. (You may also see a price, but ignore it because, as the AMA explains, it “applies to Medicare payments only and may not reflect the true cost of the services provided.”)
If the bill lacks CPT codes, ask the provider for a bill with line-item details that include CPT codes, or ask your insurance company which CPT codes the provider billed for.
Once you understand your bill, fact-check it. If nothing is amiss, you’re done. If something doesn’t add up…
2. Call your health care provider.
Call the number on your bill, which may differ from their main number. Ask for the billing department, explain the mistake you found, and ask for a corrected bill.
Just remember to be nice. For all you know, the mistake was just a typo.
Or perhaps there is no mistake – you could’ve misinterpreted a CPT code’s definition, as I learned from a medical biller I used to work with.
Here’s why: The CPT codes for established-patient office visits (99211 through 99215) are defined by specific tasks the provider performs during the visit. (Marilyn should’ve been billed for no more than a 99211.) But those definitions also mention how long each type of visit typically lasts, which can be misleading because some providers work faster than others. So evaluate your bill based on what a CPT code requires the provider to do, not how long it takes.
If the provider resolves the mistake (or clarifies why there is no mistake), you’re done. If not…
3. Call your insurance company.
Call the number on your bill or, if there isn’t one, the number on the back of your insurance card. Ask for the fraud department and explain the mistake you found as well as the provider’s response (or lack thereof). Your insurance company should be able to help you or at least direct you to an agency that can, as no insurance company wants to pay more than they have to.
Once that’s settled, you may also want to consider finding a new provider. Here’s The Right Way to Pick a Doctor.