What is the classification of upcoding services to receive higher reimbursement from Medicare/Medicaid?

Upcoding services to receive higher reimbursement from Medicare or Medicaid is classified as fraud because it involves deliberately misrepresenting services provided in order to obtain a greater payment than what is legitimately owed. Fraud encompasses intentional actions aimed at deceiving the government or payer for financial gain. In this scenario, the act of coding for a higher level of service than was actually rendered is not merely a billing error; it reflects a purposeful manipulation of billing practices with the intent to increase reimbursement illegitimately.

While abuse involves practices that may be considered unintentional but still lead to unnecessary costs or improper payments, the key difference lies in intent. Upcoding indicates a clear intent to deceive, thereby categorizing it strictly under fraud. This distinction is crucial in the realm of healthcare compliance, where understanding the nuances of billing practices can significantly affect the legal and financial standing of healthcare providers.