Upcoding Is Quietly Draining Health Plan Resources — Here's How H.H.C. Group Fights Back

June 23, 2025 Outpatient care costs are rising—and not just because of new treatments. Increasingly, it's administrative inflation driving up claim values. A new national study from Trilliant Health confirms what many payors already suspect: upcoding is accelerating across outpatient services, quietly inflating costs without always reflecting a true increase in patient complexity.

HHC Group helps you fight back.

From emergency rooms to urgent care clinics, providers are billing more visits at higher intensity levels and payors are left holding the bag. Whether it's a rash coded as a level-4 emergency or a routine urgent care visit billed at top-tier complexity, the financial pressure on stop-loss carriers, TPAs and self-insured plans is real and growing.

The Problem: Administrative Inflation That Hits Hard and Hides Well

Between 2018 and 2023, Trilliant's research shows a clear shift:

• Emergency visits coded at level 4 rose from 32.5% to 39.6%
• Urgent care level-4 visits grew from 34% to 40.6%
• Physician office level-4 visits increased from 38.5% to 45%

Meanwhile, low-intensity coding dropped significantly, suggesting this isn't about sicker patients, it's about shifting documentation strategy, billing software templates and an evolving reimbursement mindset.

The result? Plans are paying more for care that may not be any more intensive, medically necessary or resource-consuming than before. Additionally, most don't catch costly upcoding because it looks like legitimate coding on paper.

This isn't fraud. It's administrative behavior. The impact on your bottom line is the same.

HHC Group's Response: Real Oversight for Real Savings

This is where HHC Group gives you the edge. We don't just reduce costs, we root out the trends that quietly drain plan resources and back every action with clinical and regulatory credibility.

Here's how we help you stop upcoding from eroding your margins:

• Comprehensive Bill Reviews: HHC Group breaks down every detail to catch inflated coding, unnecessary charges and billing patterns that don't align with actual care delivered.


• DRG Validation at the Claim and Medical Record Level: HHC Group validates diagnosis-related group (DRG) assignments using both claim data and full medical records to identify upcoding and ensure coding reflects true clinical complexity.


• Negotiators Identifying Inappropriate Charges/Modifiers: HHC Group's experienced negotiators are trained to spot and challenge excessive charges and improper modifier use directly on claims before they impact your spend.

Payors Can't Afford to Let This Slide

As the study makes clear, upcoding isn't isolated — it's systemic. Without active oversight, these billing trends will continue to drive renewal rates up, blow past budgets and erode trust across your provider and plan networks.

This isn't just about catching errors. It's about restoring balance between the care delivered and the costs incurred and doing it with speed, certainty and regulatory confidence.

Contact HHC Group to help you reclaim control. We provide the tools, talent and clinical firepower to push back against passive revenue optimization and replace it with smart, proactive cost containment.

Real Oversight. Real Control. Real People. Real Savings.