Identifying and Reporting Upcoding
Upcoding can be difficult to detect. Medical diagnoses, the length of office visits, and the complexity of treatments are left to the discretion of healthcare providers. Individual cases of this criminal behavior, or even small clusters of them, can be nearly impossible to find or prove. Frauds can be even more pervasive and more difficult to uncover in large institutions like laboratories or hospitals, which have greater ranges of procedural options and where Medicare billing tends to be lax.
Emergency rooms, in particular, are a common site of misrepresentation, and are estimated to cost the U.S. Government an extra $1 billion per year. Further complications may arise with the use of Electronic Health Records (EHR), which can be prone to error and are easier to alter than traditional methods. Moreover, electronic records remove doctors further from the coding process and place it more firmly under the review and control of hospital administrators.
While excessive institutional scams may lead to billing anomalies that could be noticed by investigative agencies, qui tam whistleblowers remain the best tool for discovering widespread fraudulent practices. Physicians, accountants, administrators and the executives of medical institutions are the people most frequently in the position to take a step forward and report the crime.