The financial health of a practice relies heavily on accurate medical coding. Selecting the wrong code is not only much more likely to result in a claim denial but it can lead to the wrong treatment being given, as well as illegal consequences. This usually happens in three ways: the facility ends up choosing a code for a milder treatment than what is really needed (undercoding), chooses a code for a more expensive treatment (upcoding) or reports separate procedures that can usually be combined, therefore falsely increasing reimbursement (unbundling).
In some cases, upcoding is accidental. A coder may misread clinical documentation or misunderstand a diagnosis due to lack of physician documentation and may inadvertently choose the code for a more expensive treatment. However, some practices have exhibited intentional upcoding and unbundling.
Both intentional and non-intentional upcoding can have damaging effects on providers. To prevent this, providers looking to ensure they have accurate medical coding and true reimbursements should partner with an experienced medical coding company. ECLAT Health Solutions can guarantee a 95% coding accuracy or greater to ensure our clients prevent these inaccuracies. Below, we’ll cover the various consequences providers can avoid by choosing to work with our medical coding experts:
Potential Increased Financial Burden on Provider
When upcoding or unbundling is successful, of course, the facility enjoys falsely-acquired, increased revenue. However, the financial consequences of when this fraud is detected far outweigh the benefits. If the incorrect code is discovered by the insurance provider during claims processing, this will result in a claims denial, which can carry a hefty price tag.
This is nothing compared to the cost of being reported and found guilty of healthcare fraud. Last year, Carolinas Healthcare faced a $6.5 million fine for upcoding lab test results. They received $80 more per urine test they conducted than they should have, resulting in false revenue. This revenue did not surpass, however, the huge fine they ended up paying.
Providers should not take this financial burden lightly. Choosing coding specialists like ECLAT Health Solutions is the best way to ensure all codes are chosen accurately and the provider steers clear of fines.
Potential Increased Bills for Patients
Upcoding and unbundling is bound to result in a higher cost for a patient. There has been a large increase in financial responsibility falling to the patient in recent years, and upcoding and unbundling can only contribute to this. If a patient’s insurance does not fully cover the more expensive treatment reported with the coding, they will need to pay more out of pocket. This can in turn affect their decision to remain loyal to a provider or seek elsewhere for less expensive treatment, which ultimately affects revenue.
Coding Audits & Investigations
Providers who draw attention with their upcoding are likely susceptible to coding audits or criminal investigations. Because upcoding and similar fraud like unbundling costs the healthcare industry billions of dollars annually, the penalties for these offenses are severe. Not only does upcoding cost facilities a lot of money, as in the case of Carolinas Healthcare, but can damage their reputation and credibility with patients, insurance providers, and other practices alike. Even if a provider is not found guilty of upcoding, investigations send a negative impression to the public.
HHS has begun cracking down on healthcare fraud and developed a proactive approach to fraud protection that hopes to detect more fraud issues. Part of these measures include using predictive analytics to prevent false medical bills. It has become increasingly crucial that providers take every possible measure to prevent upcoding, whether intentional or unintentional. There are serious legal implications and consequences of fraud and abuse. Learn more about these implications here.
Choose ECLAT, Your Trusted Medical Coding Company
Trusting a medical coding company to handle your daily coding is the best way to ensure accurate codes and no upcoding. ECLAT Health Solutions not only helps providers increase their coding accuracy but identify potential inefficient practices or other areas of concern to prevent accidental, or intentional, upcoding. It is everyone’s responsibility to report accurate information based on patient documentation, reflecting the severity of our patients and the costs associated. We work closely as an extension of our clients to help them become proactive in their coding practices and earn a true ROI.