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The problem and potential consequences of upcoding

A physician’s duty is to their patient. While this is true, medical professionals have many other responsibilities as well. There are hospital and clinic rules that you must follow. You must adhere to state and national regulations, and you have ethical obligations to uphold. Your medical license comes with strings attached.

In your pursuit of providing the best care for your patients, obstacles like hospital funding for certain tests or equipment or insurance claim denials may occasionally prevent the administration of ideal treatment. In such cases, some physicians—out of compassion—could feel tempted to bend the rules to get a patient the treatment they need using what’s called upcoding. However, these individuals do so at great professional risk.

The Center for Medicare and Medicaid Services categorizes upcoding as one of the four types of medical billing fraud. Fraud in the U.S. healthcare system costs $100 billion annually. It affects all aspects of healthcare costs down to individual insurance premiums.

A definition of upcoding

Physicians who game the system for the patient’s best interest use upcoding. This could involve exaggerating the nature of a patient’s condition in a hospital setting to delay discharge, splitting one test into two or reporting symptoms that are not present to secure a test. This manipulation of the billing system may seem fine, but it is unethical. It can put your medical license at risk.

What medical misconduct could mean for your future

The choice to act benevolently on one patient’s behalf by upcoding could change the course of your future if an administrative audit or a colleague reports what they suspect is medical misconduct to your state medical board. You can be prosecuted for fraudulent behavior, and there may be both civil and criminal consequences. A medical license is a privilege that you worked hard for. Maintaining your ethical obligation to the public will allow you to keep that privilege and serve clients well for the duration of your career.