Ethical Decisions in Medical Records Paper: Coding Accuracy, Reimbursement and Fraud Cases, Plus EHR Journal Article Review

Part I: Ethical Decisions in Medical Records Paper

Research examples of current illegal and unethical practices in healthcare reimbursement. Articles should be no more than 10 years old and discuss unethical and illegal practices in detail.

• Search for current event articles and stories about recent unethical and illegal practices by hospitals and physicians.
• Identify the importance of accuracy in coding and how it affects reimbursement.
• Include research that clearly demonstrates illegal and unethical practices.
• Explain healthcare reimbursement and how fraud affects the reimbursement process as a whole.
• Use at least 3 scholarly sources in addition to the course textbook and the Bible, 750–1,000 words, APA format.

Part II: Journal Article Review

Research Electronic Health Records (EHR), specifically the process and challenges of converting from a paper record system to an EHR.

Original example for study purposes (about 870 words, within the 750–1,000 range). Add your course textbook where shown, and write the submitted version in your own words, since it will be checked by Turnitin.

Ethical Decisions in Medical Records: Coding Accuracy, Reimbursement and Fraud

Every diagnosis and procedure code recorded in a patient’s chart becomes a financial claim. Because payment depends on what the record says, health information professionals and providers hold a responsibility that is both technical and ethical. This paper explains how healthcare reimbursement works, why accurate coding matters, recent examples of illegal and unethical practices and how fraud damages the reimbursement system.

Healthcare Reimbursement and the Role of Coding

Most payers do not reimburse providers for time or effort alone; they pay for documented, coded services. Hospitals treating Medicare inpatients are paid by diagnosis-related group (DRG), which is determined by the principal diagnosis, secondary diagnoses and procedures coded in ICD-10-CM and ICD-10-PCS. Physician and outpatient services are billed with CPT and HCPCS codes, including evaluation and management (E/M) levels that reflect complexity. In Medicare Advantage, the federal government pays private plans a monthly amount adjusted by each enrollee’s risk score, which rises with the number and severity of coded diagnoses [Course textbook, Year]. Coding therefore translates clinical care into payment. Accurate coding ensures that providers receive the payment they have earned, supports valid quality and public health data and protects patients from billing errors. Inaccurate coding, whether through carelessness or intent, produces improper payments, and when it is knowing and deliberate, it becomes fraud under the False Claims Act.

Recent Illegal and Unethical Practices

Medicare Advantage diagnosis inflation. In January 2026, Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that they submitted invalid diagnosis codes to increase Medicare Advantage payments from 2009 to 2018 (U.S. Department of Justice [DOJ], 2026). The government alleged that Kaiser mined patients’ past records for diagnoses, then pressured physicians to add them through addenda written months or more than a year after the visit, often unrelated to the visit itself. Kaiser allegedly set diagnosis goals for physicians and facilities and tied bonuses to meeting them, and ignored warnings from its own physicians and compliance audits. Kaiser resolved the case without an admission of liability, but the allegations show how financial incentives can corrupt documentation when organizations reward code capture instead of accurate records.

Automated emergency department upcoding. In November 2024, UCHealth in Colorado agreed to pay $23 million to resolve allegations that, from 2017 to 2021, it automatically coded certain emergency department visits at CPT 99285, the highest level, whenever vital signs were checked more times than the number of hours the patient was in the department (DOJ, 2024). The government alleged that this rule did not reflect the hospital resources actually used. This case illustrates that technology can scale unethical coding: a single flawed rule can generate thousands of inflated claims.

Research suggests these cases are part of a broader pattern. Geruso and Layton (2020) found that Medicare Advantage enrollees received risk scores 6% to 16% higher than comparable traditional Medicare enrollees, implying billions of dollars in excess public spending. Crespin et al. (2024) found that hospital discharges coded at the highest intensity rose 41% from 2011 to 2019 in five states, while changes in patient and hospital characteristics would have predicted only 13% growth, linking upcoding to about $14.6 billion in payments in 2019. Coustasse et al. (2021) similarly concluded from a literature review that upcoding contributes substantially to Medicare fraud and abuse. Not all coding intensity is fraud, since more complete documentation can be legitimate, but the line is crossed when codes are unsupported by the record or added mainly for payment.

How Fraud Affects the Reimbursement Process

Fraud harms the entire system. First, it increases costs for taxpayers, employers and patients, because improper payments are funded through higher premiums, cost sharing and public spending. Second, it distorts payment rates: when coded severity rises without real changes in patient health, payers may cut rates or apply across-the-board adjustments, penalizing honest providers. Third, it increases administrative burden, as payers add audits, prior authorizations and documentation requirements that slow legitimate claims. Fourth, inflated diagnoses corrupt patients’ medical records and research data, which can lead to inappropriate care. Finally, fraud erodes trust between patients, providers and payers. For organizations, the consequences include treble damages, civil penalties, exclusion from federal programs and reputational harm.

An Ethical Response

Health information professionals should code only what the documentation supports, query physicians in a neutral, non-leading way and refuse to participate in practices designed to maximize payment rather than accuracy. Organizations should audit coding regularly, separate compensation from coding volume and protect employees who report concerns. From a Christian perspective, these duties reflect biblical standards of honesty. Proverbs 11:1 teaches that “a false balance is an abomination to the LORD, but a just weight is his delight” (English Standard Version, 2001/2016), and Luke 16:10 reminds believers that faithfulness in small things leads to faithfulness in much. Each accurate code is a small act of integrity that protects patients and the public.

Conclusion

Accurate coding is the foundation of fair reimbursement. Recent cases involving diagnosis inflation and automated upcoding show how incentives and technology can push organizations toward fraud, with costs that spread through the entire healthcare system. Ethical coding practices, strong compliance programs and personal integrity are essential to keep the reimbursement system honest.

References

[Course textbook in APA format.]

Coustasse, A., Layton, W., Nelson, L., & Walker, V. (2021). Upcoding Medicare: Is healthcare fraud and abuse increasing? Perspectives in Health Information Management, 18(4).

Crespin, D., Dworsky, M., Levin, J. S., Ruder, T., & Whaley, C. M. (2024). Upcoding linked to up to two-thirds of growth in highest-intensity hospital discharges in 5 states, 2011–19. Health Affairs, 43(12). https://doi.org/10.1377/hlthaff.2024.00596

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Geruso, M., & Layton, T. (2020). Upcoding: Evidence from Medicare on squishy risk adjustment. Journal of Political Economy, 128(3), 984–1026. https://doi.org/10.1086/704756

U.S. Department of Justice. (2024, November 12). UCHealth agrees to pay $23M to resolve allegations of fraudulent billing for emergency department visits [Press release]. https://www.justice.gov/archives/opa/pr/uchealth-agrees-pay-23m-resolve-allegations-fraudulent-billing-emergency-department-visits

U.S. Department of Justice. (2026, January 14). Kaiser Permanente affiliates pay $556M to resolve False Claims Act allegations [Press release]. https://www.justice.gov/opa/pr/kaiser-permanente-affiliates-pay-556m-resolve-false-claims-act-allegations

Original example for study purposes (about 350 words).

Article: Kruse, C. S., Kristof, C., Jones, B., Mitchell, E., & Martinez, A. (2016). Barriers to electronic health record adoption: A systematic literature review. Journal of Medical Systems, 40, Article 252. https://doi.org/10.1007/s10916-016-0628-9

Summary

Kruse et al. (2016) conducted a systematic literature review to identify the barriers that slow healthcare organizations’ move from paper records to EHRs. The authors searched CINAHL, PubMed and Google Scholar for peer-reviewed articles published in the previous five years, screened 154 abstracts and included 27 articles, with at least two reviewers examining each article. They identified 39 distinct barriers that appeared 125 times across the literature. The most frequently cited barrier was initial cost (14.4% of occurrences), followed by technical support (8.0%), technical concerns (7.2%), resistance to changing work habits (6.4%), maintenance and ongoing costs (6.4%) and training (5.6%). Insufficient time, privacy concerns and workflow challenges were also common. The authors concluded that policymakers should consider incentives that further reduce implementation costs, especially for small and rural hospitals, which adopt EHRs at lower rates.

Analysis

A strength of the article is its systematic method, which combines evidence from many settings and gives a frequency-based picture of the barriers rather than one organization’s experience. Its findings show that conversion is as much a human and organizational challenge as a technical one: resistance to new work habits, training and workflow disruption appear alongside cost. A limitation is that the review counts how often barriers are mentioned rather than measuring how severe each one is, and the included studies predate later interoperability rules, so some technical barriers may have changed. The review also relies on English-language studies indexed in a few databases.

Application to Medical Records Practice

For a health information management department planning conversion from paper or a hybrid record, the article suggests budgeting for ongoing maintenance and support, not just purchase; involving clinicians early to redesign workflows; providing role-based training; and planning privacy and security safeguards from the start. Converting legacy paper records also requires decisions about scanning, abstracting key data and retention, so that the legal health record remains complete during the transition.

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