# Upcoding **Upcoding** is the practice of recording more, or more-severe, diagnoses than a patient's condition warrants in order to extract higher reimbursement. In [[Medicare Advantage]], where [[CMS]] pays insurers more for sicker enrollees through **risk adjustment**, upcoding (also called risk-score gaming) is the central fraud allegation of the era. ## Why It Matters Upcoding is the mechanism by which the privatized side of Medicare is alleged to overcharge the government — studies and watchdogs estimate MA risk-score inflation costs taxpayers tens of billions annually. The [[Department of Justice]] has open investigations into whether [[UnitedHealth Group]] inflated diagnoses to raise [[CMS]] payments, and [[Humana]] and peers face related scrutiny. It is the payer-side analogue to the [[For-Profit Hospital]] service-line economics in the [[Healthcare Industry Ecosystem]]: the business model and the abuse run through the same incentive. See [[Managed Care]].