What is a potential consequence of coding fraud such as Upcoding or Unbundling?

What is a potential consequence of coding fraud such as Upcoding or Unbundling?

• A. You could go to jail for coding fraud
• B. It improves audit outcomes
• C. It has no consequences
• D. It reduces payment

Answer: (A)

Upcoding or unbundling is illegal because it involves billing for more extensive services or for components that aren’t justified by what was actually provided. That kind of fraud against a payer can lead to criminal charges and imprisonment. In addition to potential jail time, there are civil penalties, required repayment of funds, and possible exclusion from federal health programs. The other options don’t fit: fraud does have consequences, it doesn’t improve audits, and while it can affect payments, the serious consequence most closely associated with this behavior is criminal liability.

Upcoding or unbundling is illegal because it involves billing for more extensive services or for components that aren’t justified by what was actually provided. That kind of fraud against a payer can lead to criminal charges and imprisonment. In addition to potential jail time, there are civil penalties, required repayment of funds, and possible exclusion from federal health programs. The other options don’t fit: fraud does have consequences, it doesn’t improve audits, and while it can affect payments, the serious consequence most closely associated with this behavior is criminal liability.