When a medical provider bills for a more complex service than was actually rendered, what is this practice called?

The practice of billing for a more complex service than what was actually rendered is known as upcoding. This is a fraudulent act where the provider intentionally assigns a code that reflects a higher level of service to inflate the reimbursement amounts from insurers or patients. By doing so, the provider misrepresents the medical service provided, which can lead to significant financial losses for insurance companies and contribute to higher overall healthcare costs.

Upcoding is particularly concerning in the healthcare industry as it undermines the integrity of medical billing and can lead to legal consequences for providers who engage in this practice. It can also impact patient care if it results in audits or increased scrutiny from payers.

In contrast, downcoding refers to the opposite scenario, where a provider bills for a less complex service than what was performed. Overbilling generally encompasses a broader range of billing errors or misconduct, while underbilling indicates charging less than what is appropriate. Each of these practices relates to inaccuracies in billing, but upcoding specifically captures the act of misrepresenting the complexity of the service for the purpose of financial gain.