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Common Medical Billing Fraud

Upcoding & Upbundling-Common Medical Billing Fraud

What Are Upcoding And Unbundling?

Healthcare fraud occurs when a healthcare provider knowingly provides false or misleading information to determine the number of healthcare benefits to pay. However, upcoding and unbundling are typical types of healthcare fraud 2022.

Medical billing fraud can occur in several ways. Some of the most common are encryption, decryption, and billing for unserved services. However, many other fraudulent schemes exist. When a service provider submits a fraudulent invoice for payment, it can be liable under the False Claims Act, and whistleblowers play an important role in exposing such fraud. 

Sometimes genuine healthcare providers are often accused of evasion, teardown, and other forms of healthcare fraud. If you are accused of renewal, termination, or any other form of health care fraud, you should contact a health care fraud defense attorney immediately. 

Difference Between Upcoding and Unbundling 

Upcoding happens when a healthcare provider sends a procedure or diagnostic code that is more expensive than performing or diagnosing. When healthcare providers update medical bills for Medicaid and Medicare patients, they defraud these programs of necessary funds.

On the other hand, Medicare and Medicaid typically offer lower reimbursement for combinations of procedures that are typically performed together, such as closures and surgical accidental incisions. A split, also known as bundling, occurs when a healthcare provider illegally bills a bundled procedure separately, causing Medicare and Medicaid to overpay. The Justice Department indicted the vendor involved in the unbundling.

Coding, Bundling, and Electronic Health Records (EHR)

Healthcare providers sometimes use electronic health record (EHR) software to facilitate coding and elaboration. Using electronic health record software, medical providers can copy and paste notes from a patient’s last visit to each current treatment note. This can make it appear that the provider has diagnosed and treated all of the conditions on the list. Additionally, vendors sometimes limit their EHR software listings to only show high reimbursement rates for diagnosis and treatment codes.

Common Unethical Medical Billing Practices

There is no time limit to these reports, but it is recommended that you report this behavior as soon as possible. If the investigation uncovers any wrongdoing by the healthcare provider, the case will be referred to the Department of Health Committee or Membership Committee for approval of disciplinary action.

This can be in the form of fines, advice, restricted practice, retraining, revocation of licenses, etc. If the facility itself is at fault, there are no criminal or civil penalties, but you must correct the violation.

For example, you might receive the lowest level of emergency room service but charge the highest level. This is illegal and fraudulent and you should ask your healthcare provider to correct the charges immediately.

Repeat charges.

 It is related to the number 1 because it is also a form of overbilling. As the name suggests, the same procedure is billed twice. If you’ve left out something on your medical bill or a benefit description, you’ll see why this may be your preferred way to get the most from your patients.

Phantom fee.

 This means that patients don’t pay for incorrect services, but for services that are not provided.


Unbundling means separating charges that would otherwise be billed under the same activation code. Unless you’re a certified medical billing programmer, it’s hard to spot errors like this, but you can refer to the code. If you suspect such an error on your bill, please contact the correct state centers for Medicare and Medicaid Services immediately.

Wrong amount.

 Unscrupulous medical billers can increase costs to patients by inflating the total number of items or medications a patient receives.

Ways for Avoiding and Detecting Unethical Billing Practices

With thousands of billing codes, not everyone can interpret your bill, so we’ve provided some tips to help you.

Completely informed

The best advice we can give you is to educate yourself about healthcare laws and familiarize yourself with your account statements and CPT codes.

Whether you are a healthcare recipient or healthcare provider, this will help ensure that every statement you receive or make is always accurate.

Keep documentation up to date and appropriate

Patients and medical providers should always make every effort to provide up-to-date and up-to-date documentation. Not only does this ensure that all the information on the bill is correct, but it also helps the doctor provide the best possible treatment and service.

Transparency Guarantee

Healthcare providers must immediately address concerns about unethical coding practices by their employees or colleagues. It should be transparent and foster cross-functional collaboration to ensure unethical employee behavior is addressed accordingly.

Therefore, all healthcare providers should be familiar with the currently required coding and classification systems. Failure to investigate or declare appropriate code must be resolved immediately.

System monitor

Healthcare providers should always strive to improve the accuracy of the coding process. They must ensure that both healthcare and coding professionals understand the ethics and standards they must follow.

The AHIMA Ethical Coding Standard must be followed and implemented at all times in the workplace. This will help ensure that the expectation of making ethical decisions in the workplace and upholding integrity in the coding process is always reflected in the work of employees.

I-MedClaims Medical Billing Services

Just like you and your caregivers, I-Med Claims medical billing experts want to provide the very best for your patients and your practice. Our staff has experience and knowledge in every part of the medical billing revenue cycle. They are also proactively prepared for changes and updates to medical billing codes and best practices in the healthcare industry.

With honest, hardworking, and ethical billing professionals by your side, you’ll never have to worry about any unethical medical billing practices.

Contact us today and let’s reach another level with our exceptional services.

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