Which term refers to fraudulent upcoding within the Medicare prospective payment system?

The term that refers to fraudulent upcoding within the Medicare prospective payment system is "RUG Creep." This term specifically relates to the Resource Utilization Groups (RUGs), which are used to classify patients in skilled nursing facilities for payment purposes under Medicare. RUG Creep occurs when providers intentionally code for higher levels of care or services than were actually delivered, thereby increasing their reimbursement rates. This practice is considered fraud as it misrepresents the actual resources used for patient care, leading to higher payments from Medicare than what is warranted based on the services provided.

Other terms, while they may relate to billing practices, do not specifically address the context of upcoding within the Medicare payment framework. For instance, "Billing Creep" and "Claims Creep" could refer to general increases in billing practices over time or potential fraudulent claims, but they do not specifically denote the particular actions described by RUG Creep. "Service Creep" suggests an increase in the number or scope of services provided but lacks the specific connection to upcoding and the Medicare prospective payment system. Therefore, RUG Creep is the precise term needed to describe this fraudulent behavior in the healthcare reimbursement context.