Rooting Out Errors and Fraud Based on Upcoding and Unbundling

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rooting out errors and fraud based on upcoding and unbundling

Have you ever taken a look at the papers that come in the mail shortly after your doctor’s visit, or do you read the words “This is not a bill” and throw it in the—ever-growing—shred pile that you’ll get to later?

You should always take a look at this explanation of benefits that is sent to you by your insurance because it will break down the services and procedures they were told you received at your doctor’s office, what portion of the cost they will cover, and if there is anything that you are expected to still owe after insurance has paid their portion.

You wouldn’t just toss your credit card statement in the shred pile without making sure that you recognize all the charges on it. Why would you do the same thing with your health information?

There are two ways providers can get more from your insurance company than they are really owed. Read below for more information about Upcoding and Unbundling.

What is Upcoding?

Just like when you are upcharged at the mechanic for a premium version of synthetic oil, upcoding is when a code for a more expensive treatment or service is used instead of the correct code which would bill at a lower amount.

One primary example of this is when a code is used to indicate that services were provided by a physician, when in reality they were actually provided by a registered nurse. This causes a discrepancy because services performed by a physician are reimbursed for a higher amount than services that are performed by a nurse.

Evaluation and management codes have different levels depending on what kind of office visit it is to evaluate and manage the condition of the patient. Another example of upcoding is to use a code that is a higher level than that of the provided service or treatment.

In terms of conditions, there are two different forms they can take: acute, meaning the condition developed suddenly and/or only lasts a short time, and chronic, meaning that the condition develops slowly and can last for a significant period of time.

In some cases, a chronic condition may be the proximal cause of an acute condition: such as chronic osteoporosis weakening the bones to the point where a minor impact causes a broken bone, which is an acute condition. This is not the same thing as an acute condition being described as a chronic one.

What is Unbundling?

Sometimes in order to determine or rule out certain illnesses, a number of tests are run at the same time: for example, different tests done from the same blood draw to screen for blood sugar, lipids, etc.

When lab tests are commonly performed together, they are often “bundled” to reflect that it was intended for them to be done at the same time, and so they are reimbursed at a lower rate because they can be performed together as opposed to having to be run separately.

When these kinds of tests are “unbundled” and billed individually instead of together as they should be it means that the payer pays more than they should, regardless of whether it is a private insurer, Medicare or Medicaid.

Another example of unbundling is when anesthesia is unbundled from a cardiac procedure. There are very specific circumstances in which this can be done, and it is when there is a separate procedure performed that would not ordinarily be done on the same day, by the same surgeon.

Is It Fraud or Is It An Error?

There are thousands upon thousands of CPT codes that are used to report services and treatments to health insurance payers to reimburse the providers. Every now and then, there are bound to be errors where someone enters the wrong code, or misinterprets a treatment and puts individual codes instead of combining them together.

However, take a careful look at your explanation of benefits when it arrives in the mail (or when you check it on line) if there is a pattern of seeing amounts billed higher than they have been previously, or if you see items on there that you don’t remember, give your doctor’s office a call and see if they can explain it to you.

Billing for services is a complicated process, and it is not always straightforward to determine what is and is not appropriate billing. Medical billing experts can look over your records and determine where there are inconsistencies and help you if you have doubts.

Furthermore, if a provider is regularly and intentionally upcoding or unbundling to increase the amount they are billing to insurance, this is fraud, and there are severe penalties if they are found practicing fraud, which is all the more reason to enlist medical billing experts if things do not look right to you.

Why You Need Medical Billing Analysts

It is highly recommended to hire medical billing experts to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, one of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses and based on local CPT codes they can also perform a Cost Projection Analysis of future costs. Through meticulous analysis, we can justify reasonable cost of services which assists in resolving the case.

Contact Medical Billing Analysts by phone or email at 800-292-1919 or We’re here for you, whether you need an evaluation of a single charge, or a complex injury case.