When Prevention Gets Billed as Diagnosis

Preface: I know, as some of you read this, you're going to be thinking, 'McGovern, aren't you just an executive recruiter? Stay in your lane.' And I get that. And I am no expert in medical coding or 'upcoding' (perhaps more amusingly, my only academic training is in political science and jazz performance) - but, I am a concerned citizen with some relevant experience and a soapbox - and this issue warrants me climbing up there.

Introduction: I Know What Upcoding Is, and It Still Almost Got Me

Let’s talk about upcoding. Most of you reading this probably know exactly what it is: a provider uses a higher-level CPT code than is medically justified to increase reimbursement. It’s not always malicious, but let’s not kid ourselves, it’s widespread, it’s systemic, and it’s eroding trust in our healthcare system.

I’m a healthy 50-year-old male. No major conditions. Normal blood pressure. Normal weight. No cholesterol issues. I’m not saying that as a point of pride - I’m lucky, and I know it. I also happen to be a healthcare executive search leader who’s been in and around this system for over 20 years. I know just enough about coding and billing to be dangerous.

And yet, in my last two experiences trying to access basic, ACA-covered preventive services, I ran head-first into blatant upcoding.

If it can happen to me, what’s happening to patients who don’t know what upcoding is?

Case 1: My “Preventive” Colonoscopy Nearly Cost Me $5,000

At 49, I was due for my first colonoscopy. The ACA makes this a no-cost preventive service for adults over 45. My primary care physician referred me accordingly, no symptoms, no family history, just routine preventive care.

Then the bills started showing up. Nearly $5,000. Why? Because the gastroenterology group had coded it as a diagnostic colonoscopy.

I spent hours, emails, phone calls, appeals, trying to correct it. The night before the procedure, after fasting, prepping, and rearranging my schedule, I still hadn’t gotten clarity. I told them flat out: if I’m asked to pay, I’m walking out.

Miraculously, it got resolved after I invoked the Virginia Department of Insurance and explicitly used the term “upcoding.” Funny how fast things change when those words enter the conversation.

Case 2: An $18.27 Bill That’s Cost Me Hours

More recently, I went in for my annual wellness exam, again, an ACA-covered preventive visit. Routine bloodwork was ordered, including a lipid panel. No red flags, no symptoms, no underlying conditions.

Weeks later, I got a bill: $18.27. Not a lot of money, but the explanation? The lipid panel was coded as diagnostic.

Now I’m two months into trying to reverse it. I’ve shown them the normal lab results. I’ve referenced the ACA preventive service rules. I’ve spoken to my insurer. I’ve submitted a formal complaint to the Virginia Department of Insurance. Still unresolved.

Would most people just pay it and move on? Probably. And that’s the problem.

My Wife’s Experience: One Bad Day, Three Diagnoses, and a Growing Tab

If this weren’t ridiculous enough, my wife had her annual wellness exam at a different practice around the same time. The doctor asked how she was doing. She said, “Fine. Just having a rough day.”

That led to three psychological distress codes being added to her record, none of which were discussed, diagnosed, or even mentioned during the visit. Just like that, her ACA-covered wellness exam was transformed into something else entirely.

She’s still disputing the upcoding months later, and she’s now also being billed for those incorrect codes. Yes, she’s fighting those charges too (around $250).

Indignant Billing & Practice Administrators

To add insult to injury, in all three cases of upcoding, my wife and I were treated dismissively and indignantly by each of these provider offices. At one point, the gastroenterologist's billing manager yelled into the phone, "you can't tell the doctor what code to use." I must admit in that case, I couldn't resist responding, in a more measured tone than what was directed at me, "actually, yes, I can." OK. I probably should have resisted saying that but, it was awfully satisfying at the time.

All this to say, no one wants to be reporting their provider's office to the Department of Insurance. No one wants to have adversarial relationships with their healthcare providers. But, after being run around in circles for hours upon hours on call after call, letter after letter, patience does run out.

This Isn’t About the Money, It’s About Trust

Here’s the thing, I’ve now spent more than a dozen hours fighting a bill for $18.27. That makes no financial sense. But I’m doing it because what’s happening is wrong, and because I know what it means if no one pushes back.

These “errors” aren’t rare. They’re systemic. A 2024 survey found that 90% of medical coders are concerned about upcoding fraud, and 18% say they’ve been pressured by employers to engage in it (TechTarget, 2024).

And it’s not just anecdotes. Between 2018 and 2023, outpatient visits coded at higher complexity levels rose dramatically, even for simple complaints (Trilliant Health, Fierce Healthcare).

This is not a glitch in the system, it is the system.

Why It Happens, and Who Pays the Price

I get it. Primary care practices are under tremendous financial pressure. Many are owned by health systems or PE-backed groups that demand higher RVUs, tighter margins, and faster throughput. Coding “up” becomes the path of least resistance.

But when we code a preventive service as diagnostic, we’re not just overbilling, we’re misrepresenting care, distorting patient records, and undermining one of the few parts of our healthcare system designed to be truly accessible.

And when that happens to a senior on a fixed income, to someone with limited health literacy, to a patient with real mental health concerns who’s afraid of being misdiagnosed?

We all lose.

What Needs to Change

If you’re a leader in healthcare—payer, provider, regulator—this is your problem to solve.

Here’s where we start:

Audit ACA preventive services rigorously. If lipid panels and colonoscopies are getting upcoded, the protections aren’t working.

Strengthen state Department of Insurance oversight. Patients need more than a “dispute this charge” link on a bill.

Rebuild coding incentives. Stop rewarding volume and acuity when they aren’t clinically justified.

Support patients in appealing false charges. Every insurer should offer no-cost billing advocates for routine disputes.

Final Word

Upcoding isn’t new. But it’s more dangerous now because it’s becoming invisible, baked into routine encounters, masked by administrative complexity, and accepted because “it’s just $18.”

This isn’t just about a bill. It’s about a broken system of profoundly misaligned incentives.

If someone like me, with experience, time, and knowledge, can almost walk away from covered care due to erroneous billing, what’s happening to everyone else?

It’s time to call it what it is, and fix it.

© Steve McGovern and Executive Search Insights, 2025. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to McGovern Executive Search with appropriate and specific direction to the original content.