Regional variation in medical systems data: Influences on upcoding

Abstract

Attempts to minimize over-reimbursement to health care providers have resulted in highly publicized prosecution of health care providers and provider organizations. Such prosecution has led many to propose that upcoding influences exerted upon health care information managers would largely disappear, both within and external to the provider organization. This study seeks to examine the degree of both intra-and extraorganizational influences on reimbursement optimizing practices through a national survey of accredited health information managers. Results suggest that significant upcoding influence continues to occur within organizations, despite the risk of severe counterfraud penalties designed to eliminate such practices. We examine variation in intra- and extraorganizational optimizing influences, finding such influence was found to exist both within and external to the provider organization. We also examine how optimization influences vary across demographic, practice setting, and market characteristics. We find significant variation in influence across practice settings and managed care markets. Ramifications for reimbursement assessment are discussed.