UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING?

Q3 Medicine
Alberto Coustasse, Whitney Layton, Laykin Nelson, Victoria Walker
{"title":"UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING?","authors":"Alberto Coustasse,&nbsp;Whitney Layton,&nbsp;Laykin Nelson,&nbsp;Victoria Walker","doi":"","DOIUrl":null,"url":null,"abstract":"<p><p>Medicare fraud has been the cause of up to $60 billion in overpaid claims in 2015 alone. Upcoding occurs when a healthcare provider has submitted codes for more severe conditions than diagnosed for the patient to receive higher reimbursement. The purpose of this study was to assess the impact of Medicare and Medicaid fraud to determine the magnitude of upcoding inpatient and outpatient claims throughout reimbursements. The methodology for this study utilized a literature review. The literature review analyzed physician upcoding throughout present on admission infections, diagnostic related group upcoding, emergency department, and clinic upcoding. It was found that upcoding has had an impact on Medicare payments and fraud. Medicare fraud has been reported to be the magnitude of upcoding inpatient and outpatient claims throughout Medicare reimbursements. In addition, fraudulent activity has increased with upcoding for ambulatory inpatient and outpatient charges for patients with Medicare and Medicaid.</p>","PeriodicalId":40052,"journal":{"name":"Perspectives in health information management / AHIMA, American Health Information Management Association","volume":null,"pages":null},"PeriodicalIF":0.0000,"publicationDate":"2021-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/pdf/phim0018-0001f.pdf","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Perspectives in health information management / AHIMA, American Health Information Management Association","FirstCategoryId":"1085","ListUrlMain":"","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2021/1/1 0:00:00","PubModel":"eCollection","JCR":"Q3","JCRName":"Medicine","Score":null,"Total":0}
引用次数: 0

Abstract

Medicare fraud has been the cause of up to $60 billion in overpaid claims in 2015 alone. Upcoding occurs when a healthcare provider has submitted codes for more severe conditions than diagnosed for the patient to receive higher reimbursement. The purpose of this study was to assess the impact of Medicare and Medicaid fraud to determine the magnitude of upcoding inpatient and outpatient claims throughout reimbursements. The methodology for this study utilized a literature review. The literature review analyzed physician upcoding throughout present on admission infections, diagnostic related group upcoding, emergency department, and clinic upcoding. It was found that upcoding has had an impact on Medicare payments and fraud. Medicare fraud has been reported to be the magnitude of upcoding inpatient and outpatient claims throughout Medicare reimbursements. In addition, fraudulent activity has increased with upcoding for ambulatory inpatient and outpatient charges for patients with Medicare and Medicaid.

Abstract Image

Abstract Image

升级医疗保险:医疗欺诈和滥用正在增加吗?
仅在2015年,医疗保险欺诈就造成了高达600亿美元的超额索赔。当医疗保健提供者为患者提交了比诊断更严重的疾病的代码以获得更高的报销时,就会发生编码升级。本研究的目的是评估医疗保险和医疗补助欺诈的影响,以确定在报销过程中住院和门诊索赔的升级编码程度。本研究采用文献综述的方法。文献综述分析了住院感染、诊断相关组、急诊科和诊所的医生升级编码。研究发现,升级编码对医疗保险支付和欺诈产生了影响。据报道,医疗保险欺诈是整个医疗保险报销中住院和门诊索赔的幅度。此外,随着医疗保险和医疗补助患者住院和门诊门诊费用的升级编码,欺诈活动也有所增加。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 求助全文
来源期刊
CiteScore
1.90
自引率
0.00%
发文量
0
期刊介绍: Perspectives in Health Information Management is a scholarly, peer-reviewed research journal whose mission is to advance health information management practice and to encourage interdisciplinary collaboration between HIM professionals and others in disciplines supporting the advancement of the management of health information. The primary focus is to promote the linkage of practice, education, and research and to provide contributions to the understanding or improvement of health information management processes and outcomes.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信