How to spot illegal medical upcoding

Have you ever spent hours in a waiting room that turns out to be a medical visit that only lasts a few minutes? Was the medical bill you received weeks later much higher than expected?

That inflated bill could be due to an illegal practice called upcoding.

With upcoding, your healthcare provider charges too much for the healthcare services you have received.

“It's not fraud in the sense that they billed you for services that never happened at all. It is that they charged you more for services than was necessary,” explains Adam Sacarny, assistant professor of health policy at the Columbia Mailman School of Public Health.

Imagine going to your healthcare provider to treat a sore throat.

The doctor comes by, tests you for strep throat and prescribes antibiotics. The appointment lasts a maximum of 15 minutes, but you do pay for a complex one-hour visit.

A situation may be an example of upcoding, but it is difficult to capture.

For starters, the invoice you receive in the mail may not list all of your charges. Sacarny says: If you're skeptical, it's worth investigating.

“If your invoice is more of a summary invoice, you can contact them and request a detailed invoice with sort of line-by-line level services,” he says. “You can also request a copy of the invoice from your insurer. It would be called a Statement of Benefits – or EOB.”

Even with a detailed bill, medical bills can still be confusing.

When you go to the grocery store, your receipt clearly lists each item you paid for, but with medical bills they use a system of medical codes that can be difficult to decipher.

The good news is that a simple online search can help you decrypt your services.

“That can really help you when you're trying to figure out if the code was more or less appropriate for the visit,” says Sacarny.

Experts suggest it's good practice to take a closer look at your bill.

“There are estimates of healthcare fraud that indicate it is very common. So it's not unreasonable to worry about having coding experience,” says Sacarny.

But keep in mind that not every large bill is a sign of upcoding.

“The code includes more than just the number of minutes,” Sacarny explains.

Even if you've only been to the doctor for five minutes and your symptoms are complex or difficult to diagnose, you may be charged a higher rate.

But if you're asked to pay a surprisingly high bill for the time you were struggling, you may have been charged too much.

The first step, Sacarny says, is to avoid paying the bill and notify your provider that you plan to dispute the charges.

Look up the codes to see if the codes match the services you received. If not, ask your provider to explain the additional charge, or to remove it from the bill.

“Often just start the conversation. You can make some progress by getting the bill down a little bit,” Sacarny says.

You can also talk to your insurer. Tell them that you believe an invoice has been received in error.

The last option is to file a complaint with the national healthcare regulator.

Regardless of the steps you take, experts suggest it's important to always advocate for yourself.

“What I think is really frustrating about all these issues that we're talking about now is that they happen when you're sick,” Sacarny says.

But while this may be the last thing you want to think about when you're feeling down, he says it can be worth it in the long run. “The fact is that negotiating, pushing back when you get these big bills, can sometimes really pay off.”

For starters, the invoice you receive in the mail may not list all of your charges. Sacarny says: If you're skeptical, it's worth investigating.

“If your bill is more of a summary bill, you can contact them and request a detailed bill with some kind of line-by-line services,” he says. “You can also request a copy of the invoice from your insurer. It would be called a Statement of Benefits – or EOB.”

Even with a detailed bill, medical bills can still be confusing.

When you go to the grocery store, your receipt clearly lists each item you paid for, but with medical bills they use a system of medical codes that can be difficult to decipher.

The good news is that a simple online search can help you decrypt your services.

“That can really help you when you're trying to figure out if the code was more or less appropriate for the visit,” says Sacarny.

Experts suggest it's good practice to take a closer look at your bill.

“There are estimates of healthcare fraud that indicate it is very common. So it's not unreasonable to worry about having coding experience,” says Sacarny.

But keep in mind that not every large bill is a sign of upcoding.

“The code includes more than just the number of minutes,” Sacarny explains.

Even if you've only been to the doctor for five minutes and your symptoms are complex or difficult to diagnose, you may be charged a higher rate.

But if you're asked to pay a surprisingly high bill for the time you were struggling, you may have been charged too much.

The first step, Sacarny says, is to avoid paying the bill and notify your provider that you plan to dispute the charges.

Look up the codes to see if the codes match the services you received. If not, ask your provider to explain the additional charge, or to remove it from the bill.

“A lot of times you just start the conversation. You can make some progress by getting the bill a little bit lower,” Sacarny says.

You can also talk to your insurer. Tell them that you believe an invoice has been received in error.

The last option is to file a complaint with the national healthcare regulator.

Regardless of the steps you take, experts suggest it's important to always advocate for yourself.

“What I think is really frustrating about all these issues that we're talking about now is that they happen when you're sick,” Sacarny says.

But while this may be the last thing you want to think about when you're feeling down, he says it can be worth it in the long run. “The fact is that negotiating, pushing back when you get these big bills, can sometimes really pay off.”

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