Upcoding and Unbundling: Definition, Examples, How to Avoid

Fight Medical Fraud Upcoding and Unbundling: Definition, Examples, How to Avoid

Upcoding and Unbundling: Definition, Examples, and How to Avoid

Healthcare practitioners use CPT codes for roughly 7,800 different procedures. These codes represent all operations, ailments, and medications that are now reimbursable by health insurance. A costly and prevalent kind of healthcare fraud, upcoding is only one of several.

Are you concerned about the cost of your medical care and believe it is high? CPT upcoding and unbundling may be avoided with the aid of DoNotPay!

What Is CPT Upcoding?

Upcoding is a fraud in which healthcare providers submit incorrect billing codes to health insurance to get a more considerable remuneration. Patients are given treatments that are much more costly, time-consuming, and difficult than they were by doctors, according to current procedural technology filings (CPT).

CPT codes are 5-digit codes that help billing and insurance companies identify the procedure performed. It should be straightforward, right? However, the codes can get mixed up by accident or intentionally. This may result in extra charges in Medicare or Medicaid bills.

For instance, a patient gets a routine check-up which normally has a CPT code for a reimbursement of $60. But the billing may contain a CPT code for an extended check-up instead, which results in a claim for $100.

What Is Unbundling?

Unbundling is the practice of using multiple CPT codes for individual parts of a procedure to increase payment, instead of just a sampling billing for the procedure under its one CPT code. This results in higher Medicare reimbursement.

Generally, there is a lower reimbursement rate from Medicare and Medicaid for a number of procedures that are usually “bundled” or performed together. Examples include incisions and closures incidental to surgeries. Billing codes are fragmented illegally to increase a provider’s profits.

For example, incidental procedures are not eligible for separate reimbursement. Incidental Procedures can be done at the same time as a more complex primary one, like an asymptomatic appendix removal can be performed during hysterectomy surgery.

How Does Upcoding and Unbundling Constitute Fraud?

Fraud in healthcare is characterized by manipulating CPT codes or Current Procedural Terminology (CPT). Healthcare providers like physicians and hospitals use CPT codes to charge insurance companies like Medicare and Medicaid. Medicare medical fraud is quite prevalent.

The False Claims Act is violated when the higher CPT code is submitted to the government to acquire more money illegally.

What Are Some Causes of Medicare Fraud?

Fraud is deceit to acquire an unfair advantage or deprive someone of their legal rights. You may come across the following instances of healthcare fraud and should report them.

Below are some of the examples:

  • Equipment such as wheelchairs, incontinence supplies, and diabetes supplies may all be billed without a doctor's note.
  • Phone calls, door-to-door sales, and deceptive fliers deceive consumers about health insurance coverage.
  • Billing for institutions such as nursing homes, hospitals, home health,  residential facilities, and hospice care.
  • Inaccurately describing the service or quality of the product.
  • The person providing the service is being misrepresented.
  • Non-deliverable commodities and services are billed.
  • Services that are billed but do not have enough documentation.
  • Medical billing fraud for non-medically essential things and services.
  • Requesting payment or compensation for services done in connection with subsequent procedures conducted on the same day as the original service.

Since "new patients" have been claimed to give better reimbursement, clinicians have wrongly modified their CPT codes so that they may get more money. Health care fraud has been exacerbated by upcoding and unbundling, which has become one of the most costly and widespread occurrences.

How to Report Medicare Fraud on Your Own

If you suspect medical billing fraud like upcoding and unbundling, you may report it to the following:

OfficePhone Number
Medicare1-800-MEDICARE (1-800-633-4227)
The U.S. Department of Health and Human Services – Office of the Inspector General1-800-368-1463

How DoNotPay Can Help Prevent CPT Upcoding and Unbundling

DoNotPay may help you identify the right CPT code and draft a demand letter for a bill adjustment. The hospital or health care provider might be sued in a small claims court if the problem is not handled using DoNotPay's Sue Now offering.

Preventing the upcoding of CPT codes by yourself is time-consuming, and you'll encounter problems such as resetting your password. DoNotPay is the perfect option because it simplifies the entire process.

DoNotPay will help you identify the relevant CPT code and submit a demand letter for bill rectification in just five simple steps:

  1. Search Fight Medical Fraud on DoNotPay.


  2. Tell us the date of your visit, what you were treated for, and where you were treated.


  3. Let us know what CPT code your visit was filed under. If you don't know, we'll generate a letter for you to send to your physician to request the code.


  4. Choose the correct CPT code or let us know if you want us to find it for you.


  5. And that's it! DoNotPay will automatically find the correct CPT code for your visit if you don't know it and then generate a demand letter on your behalf to send to your physician for a bill correction.


Why You Should Use DoNotPay to Prevent CPT Upcoding

When it comes to avoiding CPT upcoding, many individuals may find DoNoPay useful. Reasons to use DoNotPay include:

  • Fast: You don't have to spend hours attempting to figure out the problem with CPT upcoding or unbundling.
  • Easy: You don't have to fill out lengthy papers or keep track of all the processes required to make a report should you need to do so.
  • Successful: You may be confident that we'll do all we can to help you get the best outcome on bill correction.

DoNotPay Operates Across Many Companies, Entities, and Groups With the Click of a Button

DoNotPay can assist you with more than just one firm, organization, or person. You may use DoNotPay to connect with a wide range of people and organizations. Using DoNotPay, you may get a proper CPT code in Kentucky, just as you could if you use it in California. DoNotPay is a place to go if you're not getting what you're entitled to.

Additional Services Provided by DoNotPay

By visiting DoNotPay, you may prevent issues associated with CPT upcoding and unbundling and get other concerns addressed. When doing online research, DoNotPay is an invaluable tool that may save you countless hours.

Here are some ways DoNotPay can help:

Join DoNotPay today to find the correct CPT code and demand a medical bill correction effortlessly.

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