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Related Experiment Videos

Regional variation in medical systems data: influences on upcoding.

Daniel P Lorence1, Amanda Spink

  • 1Department of Health Policy and Administration, The Pennsylvania State University, University Park 16802, USA. dpl10@psu.edu

Journal of Medical Systems
|August 17, 2002
PubMed
Summary

Despite fraud penalties, health care information managers still face internal and external pressures for upcoding. This reimbursement optimizing practice persists within organizations, varying by setting and market.

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Area of Science:

  • Health Services Research
  • Healthcare Management
  • Medical Economics

Background:

  • Healthcare provider reimbursement is under scrutiny, leading to prosecution for over-reimbursement.
  • Concerns about upcoding influencing health information managers have led to proposals for its elimination within organizations.

Purpose of the Study:

  • To investigate the extent of intra- and extraorganizational influences on reimbursement optimizing practices.
  • To analyze how these influences vary across different demographic, practice setting, and market characteristics.

Main Methods:

  • A national survey of accredited health information managers was conducted.
  • Data analysis focused on identifying and quantifying upcoding influences.

Main Results:

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  • Significant upcoding influence persists within healthcare organizations, despite anti-fraud penalties.
  • Both internal and external organizational factors contribute to reimbursement optimization practices.
  • Influence on optimization practices varied significantly across different practice settings and managed care markets.

Conclusions:

  • Upcoding influences on health information managers remain prevalent, challenging efforts to curb over-reimbursement.
  • Understanding these influences is crucial for effective reimbursement assessment and policy development.