6-1 Discussion: Upcoding a Patient's Bill

Upcoding is a fraudulent billing practice that occurs when a healthcare provider submits billing codes to payers for diagnoses or procedures that are more serious or expensive than the provider diagnosed or performed. Fraudulent billing is not only unethical; it is also illegal. How are you going to attack the problem of (intentionally or unintentionally) upcoding bills at Mercy Vale?

In August 2019, Baylor won a False Claims Act case over alleged fraudulent upcoding. The case claimed Baylor systematically schemed to wrongly bill Medicare more than $61.8 million over seven years but was dismissed, as the judge ruled the whistleblower couldn’t substantiate the allegation.

In your discussion post, explain what happened in the case and the legal consequences and penalties. Next, look at the situation from a moral instead of a legal perspective and discuss what ethical responsibilities were ignored by the perpetrators.

After you post your initial response, react to at least two of your classmates’ initial posts. Do you have any recommendations on how to address such situations? Any success stories to share? Have you witnessed any consequences to bill-padding or inaccurate coding in your professional experience?

To complete this assignment, review the Discussion Rubric document.