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 …

Provider Based Billing In The United States: The Effect On Government Reimbursement, Victoria Walker, Uyi Lawani, Alberto Coustasse

Management Faculty Research

Introduction: Provider-based status has been a Medicare payment designation established by the Social Security Act. It has allowed facilities to bill for physician services based on facility type. Medicare reimbursement has been based on whether services were rendered at a freestanding healthcare facility or a provider-based facility. Provider-Based Billing [PBB] comprises of two separate charges from the outpatient department, including a facility charge and a professional charge.

Methodology: The methodology for this research analysis was a literature review complemented with a semi structure interview of a PBB expert. The review illustrated examples of provider-based clinics who have billed all Medicare …

Medicare Access And Chip Reauthorization Act And Rural Hospitals, Erica Kelley, Rhea Lipscomb, Jennifer Valdez, Natesh Patil, Alberto Coustasse

Management Faculty Research

The cost of health care within the United States has continued to increase, whereas the quality of patient care has generally decreased in some areas. With the continued use of Medicare's former physician reimbursement algorithm, termed sustainable growth rate, national expenditures within the United States have been expected to increase 5.6% annually. To modernize the delivery and financing of care, Congress has introduced the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which has permanently eliminated and replaced the sustainable growth rate. The purpose of this study was to review MACRA and its implementation to determine how it would …