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Regulatory Exploitation and Management Changes: Upcoding in the Hospital Industry

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  • Leemore Dafny
  • David Dranove

Abstract

This paper investigates whether management teams that fail to exploit regulatory loopholes are vulnerable to replacement. We use the U.S. hospital industry in 1985-96 as a case study. A 1988 change in Medicare rules widened a preexisting loophole in the Medicare payment system, presenting hospitals with an opportunity to increase operating margins by 5 or more percentage points simply by "upcoding" patients to more lucrative codes. We find that having room to upcode is a statistically and economically significant predictor of whether a hospital replaces its management with a new team of for-profit managers. We also find evidence that hospitals that replace their management subsequently upcode more than a sample of similar hospitals whose management did not change. (c) 2009 by The University of Chicago. All rights reserved.

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  • Leemore Dafny & David Dranove, 2009. "Regulatory Exploitation and Management Changes: Upcoding in the Hospital Industry," Journal of Law and Economics, University of Chicago Press, vol. 52(2), pages 223-250, May.
    • Handle: RePEc:ucp:jlawec:v:52:y:2009:i:2:p:223-250
    DOI: 10.1086/589705
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    Cited by:

    1. Jonas Heese, 2017. "The Role of Overbilling in Hospitals’ Earnings Management Decisions," Harvard Business School Working Papers 18-026, Harvard Business School.
    2. Bowblis John R. & Brunt Christopher S. & Grabowski David C., 2016. "Competitive Spillovers and Regulatory Exploitation by Skilled Nursing Facilities," Forum for Health Economics & Policy, De Gruyter, vol. 19(1), pages 45-70, June.
    3. Giorgio Vittadini & Paolo Berta & Gianmaria Martini & Giuditta Callea, 2012. "The effect of a law limiting upcoding on hospital admissions: evidence from Italy," Empirical Economics, Springer, vol. 42(2), pages 563-582, April.
    4. Annette Hofmann & Julia K. Neumann & Peter Zweifel, 2019. "Risky health decisions under regulatory constraints: Abortion tourism in Switzerland," Journal of Risk and Uncertainty, Springer, vol. 59(3), pages 203-237, December.
    5. Neumann, Julia Kathleen & Zweifel, Peter & Hofmann, Annette, 2016. "Camouflage and Ballooning in Health Insurance: Evidence from Abortion," VfS Annual Conference 2016 (Augsburg): Demographic Change 145874, Verein für Socialpolitik / German Economic Association.
    6. Goldring, Thomas & Jacob, Brian A. & Kreisman, Daniel & Ricks, Michael D., 2024. "Loopholes and the Incidence of Public Services: Evidence from Funding Career & Technical Education," IZA Discussion Papers 16943, Institute of Labor Economics (IZA).
    7. Hanming Fang & Qing Gong, 2017. "Detecting Potential Overbilling in Medicare Reimbursement via Hours Worked," American Economic Review, American Economic Association, vol. 107(2), pages 562-591, February.
    8. Kjartan Sarheim Anthun & Johan Håkon Bjørngaard & Jon Magnussen, 2017. "Economic incentives and diagnostic coding in a public health care system," International Journal of Health Economics and Management, Springer, vol. 17(1), pages 83-101, March.
    9. David Dranove & Christopher Ody, 2019. "Employed for Higher Pay? How Medicare Payment Rules Affect Hospital Employment of Physicians," American Economic Journal: Economic Policy, American Economic Association, vol. 11(4), pages 249-271, November.
    10. John R. Bowblis & Christopher S. Brunt, 2014. "Medicare Skilled Nursing Facility Reimbursement And Upcoding," Health Economics, John Wiley & Sons, Ltd., vol. 23(7), pages 821-840, July.

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