EconPapers    
Economics at your fingertips  
 

Upcoding: Evidence from Medicare on Squishy Risk Adjustment

Michael Geruso and Timothy Layton

Journal of Political Economy, 2020, vol. 128, issue 3, 984 - 1026

Abstract: In most US health insurance markets, plans face strong incentives to upcode the patient diagnoses they report to the regulator, as these affect the risk-adjusted payments that plans receive. We show that enrollees in private Medicare plans generate 6%–16% higher diagnosis-based risk scores than they would under fee-for-service Medicare, where diagnoses do not affect most provider payments. Our estimates imply that upcoding generates billions in excess public spending and significant distortions to firm and consumer behavior. We show that coding intensity increases with vertical integration, suggesting a principal-agent problem faced by insurers, who desire more intense coding from the providers with whom they contract.

Date: 2020
References: Add references at CitEc
Citations: View citations in EconPapers (27)

Downloads: (external link)
http://dx.doi.org/10.1086/704756 (application/pdf)
http://dx.doi.org/10.1086/704756 (text/html)
Access to the online full text or PDF requires a subscription.

Related works:
Working Paper: Upcoding: Evidence from Medicare on Squishy Risk Adjustment (2015) Downloads
This item may be available elsewhere in EconPapers: Search for items with the same title.

Export reference: BibTeX RIS (EndNote, ProCite, RefMan) HTML/Text

Persistent link: https://EconPapers.repec.org/RePEc:ucp:jpolec:doi:10.1086/704756

Access Statistics for this article

More articles in Journal of Political Economy from University of Chicago Press
Bibliographic data for series maintained by Journals Division (pubtech@press.uchicago.edu).

 
Page updated 2025-03-20
Handle: RePEc:ucp:jpolec:doi:10.1086/704756