In five states over nearly a decade, hospitals have increased how frequently they document patients as needing the highest intensity care, which has led to hospitals receiving billions in extra payments from health plans and government programs, according to a new RAND study. Among thousands of cases involving hospitals stays for 239 conditions, researchers examined how often hospitals upcoded patients to the sickest end of the care spectrum, where hospitals charge payers at the highest rate. The study found that from 2011 to 2019, the number of patient discharges documented as needing the highest intensity care increased by 41%.
Adjusting for changes in patient demographics, pre-existing comorbidities, length-of-stay and hospital characteristics, researchers estimated that the increase would have been 13% in the absence of changes in coding behavior. The study estimates that in 2019, the increase in upcoding (relative to 2011 coding practices) was associated with $14.6 billion in hospital payments, including $5.
8 billion from private health plans and $4.6 billion from Medicare. The study is published in the journal Health Affairs.
These findings add to the evidence that hospitals may move patients into the highest billing category in order to increase the amount they are paid for patient care. This suggests that government programs and private payers are paying billions more each year than what would be expected based on historical rates." Daniel Crespin, lead author of the .