ArticleFrontiers in public health2026
Drivers and effects of DRG coding abuse based on hot cheese model: a qualitative study.
Article in Frontiers in public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: The national-level China Healthcare Security Diagnosis-Related Groups (CHS-DRG) reform in China has been underway for 6 years. However, the marginal benefit of controlling medical insurance fund expenditures has been decreasing, mainly due to the emergence of game behaviors among healthcare providers. The study aimed to explore the internal driving factors, effects and their interrelationships of DRG downcoding, upcoding and ambiguous cases to propose the intervention measures based on the hot cheese model. Methods: This study was conducted through semi-structured interviews with 22 participants from various positions in hospitals in Shaanxi Province, China. The hot cheese model was introduced for qualitative analysis to systematically analyze the manifestations, subjective and objective driving factors, and internal and external effects of DRG coding abuse. Results: The subjective, objective drivers and effects of DRG coding abuse were revealed, and a hot cheese model was established, consisting of three defensive layers: layers of hospital organization environment, doctor-filled first page of medical records, and medical record/insurance department review. Conclusion: DRG upcoding should be distinguished between subjective and objective driving factors for targeted intervention. The potential effect of DRG downcoding and ambiguous cases should not be underestimated. Future research should focus on intelligent early warning by natural language processing on pre-coding of medical record texts.
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