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Intentional miscoding, upcoding or unbundling the claims can manipulate billing amounts.
The electronic medical record enables easy check-offs as documentation of actual work done, and fraud is implicated if the information is deliberately misleading, as in the example of upcoding.
Gautam Gowrisankaran received the 2016 Best Paper Award for the Workshop on Health IT and Economics (WHITE) for "Does Hospital EMR Adoption Lead to Upcoding or More Accurate Coding?
Beyond that, an estimated one-third of all auto-related medical bills have an element of fraud such as upcoding, unbundling or modifier abuse.
Prosecutors led by Stephen Chan Lee told the court that Gumila led a scheme to defraud Medicare by falsely certifying patients as being confined to their homes and requiring home health services; falsely increasing, or upcoding, claims for services; over-scheduling and double-billing patient visits, submitting false claims for providing extensive oversight of patients' home health services, and billing for tests that were not medically necessary.
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 relevant outcome variable for studying upcoding is the DRG weight.
The court found that Thayer did not satisfy Rule 9(b)'s particularity requirement, however, in two of her allegations: that Planned Parenthood violated the FCA by upcoding and "by causing other hospitals to unknowingly submit claims for abortion-related services.
The researchers acknowledge that the costs of upcoding may be offset by the benefits to the patients of more attentive care, including visits to the patients' homes.
The DRG system, like FFS, attempts to link reimbursement to the extent of care provided, but drawbacks include upcoding, overtreatment, and excessive readmissions.
Some physicians responded by upcoding --claiming greater complexity in patient encounters than was in fact the case--and fraud investigations at some centers were under way.
In contrast to linear models, nonlinear models are more cumbersome to estimate, more difficult to explain to stakeholders, and more strongly incentivize diagnostic upcoding (laying claim to both more, and more serious forms of, diseases than actually present) because of the large marginal increase in predicted expenditures for individuals with many diagnoses.
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