Upcoding of hospital admissions in Medicare Part A: Not a Significant issue Now
22 Pages Posted: 9 Mar 2021 Last revised: 20 Sep 2021
Date Written: December 30, 2020
Many studies investigating financial abuse in Medicare focus on upcoding for hospital admissions, where reimbursements requested are greater than justified by the cost of care provided. We used a different approach, analyzing audit data in 2010 -- 2018 from the Comprehensive Error Rate Testing program. Upcoding represented less than 0.5% of all Medicare fee-for-service reimbursements. Audit data does not discriminate between intentional and unintentional upcoding. We therefore used Office of the Inspector General reports, showing of all cases successfully prosecuted for healthcare fraud from 2013 -- 2019, only 0.39% were for upcoding of hospital admissions, or 7.2% of all prosecutions for hospitals. Other forms of improper billing/fraud constituted more than 90\% of all cases, both for hospital admissions and for Medicare Part B, paid on a fee-for-service basis.
Keywords: Upcoding, Medicare fraud, Medicare audits, payment reform, hospital admissions
JEL Classification: I11, I13, H51
Suggested Citation: Suggested Citation