Upcoding

Q. Insurers insist that every procedure be reimbursed according to its code. But sometimes a procedure that usually takes five minutes takes an hour. Can’t I record a higher-level code in order to get fair recompense?

A. The practice you describe is often called “upcoding” – recording a code for a procedure more expensive than the one the patient needs. It is recognized as a form of insurance fraud, or if the insurer is the government as a form of defrauding the government.

The argument you advance sounds convincing at first. After all, you are not trying to defraud the insurer, but only to get a fair payment for your investment in time. However, the argument appears specious when viewed in total context. No one expects the payment schedule to accurately reflect the time and resource investment of every single visit. The recompense for a procedure that generally takes five minutes, but occasionally an hour or more, will reflect the average amount of time – let us say ten minutes. When the procedure goes smoothly, do you “downcode” to save the insurer money and obtain only what is fair?

Furthermore, even if one particular procedure is mispriced even on an average basis, we have to consider the entire payment schedule. Some procedures pay too little compared to the effort involved, others too much. Again, do you downcode procedures that are consistently the most profitable? I am guessing that you don’t.

Another consideration is that often insurers provide for extra billing when codes don’t adequately reflect the resources needed for a procedure. There is a defined bureaucratic process involved. It is true that the paperwork involved in these claims can itself be somewhat burdensome, but that is to be expected when discussing a mechanism meant to be used only in exceptional circumstances. So the incentive to upcode is sometimes not in order to obtain fair recompense, but only in order to avoid annoying paperwork – an understandable motivation, but certainly not one compelling enough to justify insurance fraud.

After extensive research, I became aware that what I have written so far is not the entire story. Sometimes the insurance is so deficient that the underpayments by the insurance company are never balanced out, and dealing with the issue through paperwork is either impossible or totally not cost effective. This is especially likely to happen for poor people who have minimal insurance. As a result, I have heard of reputable practitioners who don’t want to turn indigent patients away but simply cannot afford to treat them without changing the codes.

Even so, I do not believe this situation can justify upcoding. The health system as a whole will have to find a solution for these underinsured individuals, but the solution is not insurance fraud. Not only is the practice fraudulent in itself, but taking an accepting attitude is nearly certain to lead to an accepting attitude towards upcoding in other cases, when it can’t be easily excused as a desire to help the needy.

According to Jewish law, fraud is impermissible even when it is employed to help the needy. If you find you cannot help needy individuals without upcoding, take as many as you reasonably can on a pro bono basis (meaning accepting only the inadequate payment from the insurer) and you will just have to turn the rest away.

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