Business Commons^™

Upcoding Medicare: Is Healthcare Fraud And Abuse Increasing?, Alberto Coustasse, Whitney Layton, Laikyn Nelson, Victoria Walker

Management Faculty Research

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 …

Is Upcoding Anesthesia Time The Tip Of The Iceberg In Insurance Fraud?, Alberto Coustasse, Mike Frame, Avinandan Mukherjee

Management Faculty Research

The question of whether there is anomalous billing in anesthesia care is beginning to be asked by operating room managers, health care administrators, policy makers, and regulators. This question may arise when an anesthesia case seems to take more time to complete than it should. Audits, when conducted, have found that an unusual number of claims end with the digits 0 or 5 as if large numbers of cases start or end on the 5-minute mark. Such a finding serves as a red flag for that practice to undergo an audit. Questions may also be raised because the percentage of …