Certified in Healthcare Compliance (CHC) 2025 – 400 Free Practice Questions to Pass the Exam

The unethical practice of billing for a more expensive service than is actually provided is known as upcoding. Upcoding occurs when providers use billing codes that represent a higher level of service or procedure than what was actually delivered to the patient. This practice is considered fraudulent as it can lead to overpayment by insurers and is against the principles of ethical billing and transparency in healthcare.

DRG creep, while related to billing practices in the context of Diagnosis Related Groups, specifically refers to the tendency of hospitals to code for more complex diagnoses or conditions than are present in order to receive higher reimbursements. This strategy aligns with the broader concept of upcoding, but does not capture the full scope of submitting incorrect codes for services rendered.

Unbundling involves billing separately for services that should be billed together as part of a single comprehensive service, which also affects overall billing integrity but is distinct from the practice of falsely representing the complexity or cost of services rendered.

Overdiagnosis pertains to diagnosing a condition that would not cause symptoms or harm to the patient if left untreated; thus, it is not directly related to billing practices but rather to the identification and classification of medical conditions.

Understanding why upcoding is identified as the correct answer is crucial in recognizing and preventing fraudulent billing practices in healthcare