Time-to-Event Estimation with Unreliably Reported Events in Medicare Health Plan Payment

Oana M. Enache and Sherri Rose

Papers from arXiv.org

Abstract: OBJECTIVE: To propose time-to-event estimators that help evaluate incident diagnostic coding and possible upcoding in Medicare as well as introduce an open-source software package that enables more reproducible methods development relevant to Medicare billing behavior. STUDY SETTING AND DESIGN: Observational analysis of simulated upcoding based on coding by insurers or providers that may be incentivized by Medicare Advantage risk adjustment. DATA SOURCES AND ANALYTIC SAMPLE: Two years of separately simulated incident health condition coding data for a Medicare Advantage population and a Traditional Medicare population where coding patterns are aligned with known practices in each program. PRINCIPAL FINDINGS: We propose several novel time-to-event estimators of incident coding intensity and possible upcoding in Medicare Advantage, including accounting for unreliable reporting. We demonstrate estimator performance in simulated data leveraging the National Institutes of Health's All of Us study and also develop an open source R package to simulate longitudinal realistic labeled upcoding data, which were not previously available for researchers. In simulations, our novel estimators recovered differences in upcoding within and across monitoring periods. Undercoding had a limited effect on our novel estimators while an existing estimator was more sensitive to undercoding. CONCLUSIONS: Our proposed estimators can help researchers and policymakers track new coding behaviors (e.g., as may be incentivized by risk adjustment formula updates) earlier and at scale while accounting for several real-world data considerations. Further, the R package we provide can be used to improve the development, accessibility, and reproducible evaluation of coding intensity and upcoding methodology.

Date: 2026-02, Revised 2026-05
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