Insurers have an incentive to "upcode
" their enrollees, but other insurers have an incentive to detect the upcoding, or to leave the individual and small-group market if they feel the risks of having to pay into the risk adjustment program outweigh the potential benefits of being in the individual and small-group markets.
The potential reasons to lower the severity of the diagnosis does create some tension with the incentive to upcode
because the APR-DRG and DRG are related.
Since I wasn't going to upcode
, what the department's directive meant for me on a practical level was that I had to see more patients.
The federal government has been taking a closer look at coding, with the concern that electronic health records are making it easier to upcode
L'operation touchera, dans une phase d'essai, les nouveaux registres du commerce, dans leur forme actuelle, qui seront codes a travers la solution technologique UPCODE
(une puce electronique) durant les trois derniers mois de l'annee en cours a precise le ministre.
In other words, counselors may be tempted to "upcode
" (Cooper & Gottlieb, 2000, p.
Suppliers and nursing homes can upcode
bills for more expensive (e.g., brand-name) items rather man the less expensive items that were actually delivered (e.g., generic equivalents).
Users also may download to their mobile phone an application developed by GossRSVP and Upcode
If probability of detection is low, profit maximizing physicians can be expected to choose higher reimbursement codes or upcode
on the margin.
Silverman and Skinner (2004) and Dafny (2005) showed that for-profit hospitals were more likely to upcode
; this is possible in our data, though we cannot identify it.
Larger hospitals and teaching hospitals were found to be associated with less upcoding, perhaps because the financial pressure to upcode
is less in these hospitals or the reputation risk from negative publicity is greater.
The authors find that "room to upcode
" is a statistically and economically significant predictor of for-profit but not of not-for-profit acquisitions in the period immediately following this policy change.