Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany.
Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany.
Health Econ. 2021 Aug;30(8):1978-1986. doi: 10.1002/hec.4272. Epub 2021 May 5.
Upcoding is a common type of fraud in healthcare. However, how audit policies need to be designed to cope with upcoding is not well understood. We provide causal evidence on the effect of random audits with different probabilities and financial consequences. Using a controlled laboratory experiment, we mimic the decision situation of obstetrics staff members to report birth weights of neonatal infants. Subjects' payments in the experiment depend on their reported birth weights and follow the German non-linear diagnosis-related group remuneration for neonatal care. Our results show that audits with low detection probabilities only reduce fraudulent birth-weight reporting, when they are coupled with fines for fraudulent reporting. For audit policies with fines, increasing the probability of an audit only effectively enhances honest reporting, when switching from detectable to less gainful undetectable upcoding is not feasible. Implications for audit policies are discussed.
编码升级是医疗保健领域中常见的欺诈类型。然而，审计政策需要如何设计以应对编码升级，这一点还不是很清楚。我们提供了关于不同概率和财务后果的随机审计的因果证据。使用一个受控的实验室实验，我们模拟了产科工作人员报告新生儿出生体重的决策情况。实验中受试者的报酬取决于他们报告的出生体重，并遵循德国新生儿护理的非线性诊断相关组报酬。我们的结果表明，当低检测概率的审计与对欺诈性报告的罚款相结合时，审计只能减少欺诈性的出生体重报告。对于有罚款的审计政策，只有当从可检测到不太有利的不可检测的编码升级不可行时，增加审计的概率才能有效地促进诚实报告。讨论了对审计政策的影响。
