Are hospitals upcoding patients to boost revenue?

Medical Economics December 4, 2024
Todd Shryock

Key Takeaways

• Hospitals increased documentation of high-intensity care by 41% from 2011 to 2019, leading to billions in extra payments.
• Upcoding practices resulted in $14.6 billion in additional payments in 2019, with $5.8 billion from private plans and $4.6 billion from Medicare.
• Diagnosis-based payment systems may incentivize upcoding, potentially leading to fraudulent practices or accurate severity reflection.
• Heart failure and shock had the largest upcoding increase, with other conditions like pneumonia and sepsis also significantly affected.
• Further research is needed to distinguish between fraudulent and accurate coding, supporting the design of improved payment models.

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A RAND study that look at five...

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