Upcoding of hospital admissions in Medicare Part A: Not a Significant issue Now

22 Pages Posted: 9 Mar 2021 Last revised: 20 Sep 2021

See all articles by Keith A. Joiner

Keith A. Joiner

University of Arizona - College of Medicine

Jianjing Lin

Rensselaer Polytechnic Institute (RPI) - Department of Economics

Juan Pantano

Washington University in St. Louis - Department of Economics

Date Written: December 30, 2020

Abstract

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

Joiner, Keith A. and Lin, Jianjing and Pantano, Juan, Upcoding of hospital admissions in Medicare Part A: Not a Significant issue Now (December 30, 2020). Available at SSRN: https://ssrn.com/abstract=3757285 or http://dx.doi.org/10.2139/ssrn.3757285

Keith A. Joiner

University of Arizona - College of Medicine ( email )

Department of History
Tucson, AZ 85721
United States

Jianjing Lin (Contact Author)

Rensselaer Polytechnic Institute (RPI) - Department of Economics ( email )

Troy, NY 12180
United States
5182762016 (Phone)

Juan Pantano

Washington University in St. Louis - Department of Economics ( email )

One Brookings Drive
St. Louis, MO 63130
United States

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