GRADING RUBRIC MUST BE FOLLOWED
TEMPLATE MUST BE COMPLETED AS WELL
Write a workplace brief (5-7 single-spaced pages) of evidence-based recommendations to identify and address upcoding, an incorrect health care billing practice. Include a description of the major categories of health care fraud and abuse and the laws designed to address them.
Instructions
In this assessment you will continue as a member of the Chief Compliance Officer’s team. Recently, an incorrect billing practice known as upcoding has been discovered. Upcoding is a common area for fraud and abuse, and the recent incident has become an area of major focus for the Chief Compliance Officer.
The Chief Compliance Officer has tasked you with researching and making evidence-based recommendations about how to identify and address this incorrect billing practice. Your recommendations will be considered for possible inclusion in future policy and procedure content.
The Chief Compliance Officer has stressed with you the importance of incorporating evidence-based recommendations. This individual is specifically interested in the Office of the Inspector General’s position on upcoding, any relevant case precedents, and any available resources for health care organizations. You know from experience that the workplace brief will need to include substantiation of all facts and recommendations from authoritative sources. The team leader has asked you cover all of the following headings in your brief:
Major Categories of Health Care Fraud and Abuse (1 page)
- Describe the major categories of health care fraud and abuse.
- Be sure to include the billing practice known as upcoding.
Five Health Care Fraud and Abuse Laws (2 pages)
- Provide a synopsis of five laws relating to health care fraud and abuse.
- Include the rationale for why you selected the laws you did.
Upcoding and the Law (1 to 2 pages)
- Explain in detail one law pertaining to upcoding.
- Be sure to explain how the law specifically applies to upcoding.
- Provide an actual example of upcoding.
- Select your example from your suggested resources, from research you conducted on the topic, or from your professional experience. If your example stems from your professional experience, please be sure to protect individual and organizational identities.
Identifying and Addressing Upcoding in Health Care (1 to 2 pages)
- Propose a list of evidence-based recommendations to identify and address upcoding in the health care environment.
- Be sure to consider in your recommendations what the Office of Inspector General has to say about identifying and addressing upcoding.
- Tip: Visit these websites:
- Centers for Medicare and Medicaid Services. (2017). Avoiding medicare fraud and abuse: A roadmap for physicians. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf
- United States Department of Health and Human Services & Office of Inspector General. (n.d.). Compliance education materials: Compliance 101. Retrieved from
Expert Solution Preview
Introduction:
Upcoding is an incorrect billing practice that has been identified as a common area for fraud and abuse. As a member of the Chief Compliance Officer’s team, I have been tasked with researching and making evidence-based recommendations to identify and address upcoding in the health care environment. This workplace brief will cover the major categories of health care fraud and abuse, five health care fraud and abuse laws, upcoding and the law, and identifying and addressing upcoding in health care.
Major Categories of Health Care Fraud and Abuse:
Health care fraud and abuse can be categorized into the following six categories: billing for services not rendered, billing for services at a higher rate than what was actually provided (upcoding), unbundling, performing medically unnecessary services, kickbacks, and misuse of the provider identification number. Upcoding is the practice of submitting a bill for a service that is more expensive than the service that was actually provided.
Five Health Care Fraud and Abuse Laws:
There are several laws designed to address health care fraud and abuse. The five laws that I have selected are:
1. False Claims Act (FCA)
2. Anti-Kickback Statute (AKS)
3. Stark Law
4. Exclusion Authorities
5. Civil Monetary Penalties Law (CMPL)
The rationale for selecting these laws is that they are the most commonly used to address health care fraud and abuse. The False Claims Act is used to combat fraudulent billing practices, while the Anti-Kickback Statute and Stark Law address fraudulent financial relationships between providers. Exclusion Authorities and Civil Monetary Penalties Law are used to exclude individuals or entities from participating in federal health care programs.
Upcoding and the Law:
The False Claims Act (FCA) is the law that pertains to upcoding. The FCA imposes penalties on individuals or entities that knowingly submit a false claim to the government. Upcoding is considered a false claim because it misrepresents the service that was provided and results in a higher payment to the provider. An actual example of upcoding is when a provider bills for a comprehensive exam when only a brief exam was conducted.
Identifying and Addressing Upcoding in Health Care:
To identify and address upcoding in health care, the following evidence-based recommendations should be considered:
1. Conduct regular audits of billing practices to identify any patterns or discrepancies that may indicate upcoding.
2. Educate providers and staff about upcoding and its potential consequences.
3. Implement a compliance program that includes policies and procedures to prevent upcoding and other fraudulent billing practices.
4. Encourage employees to report any suspicious or questionable billing practices.
5. Follow the recommendations provided by the Office of Inspector General to identify and address upcoding.
Conclusion:
Upcoding is an incorrect billing practice that can result in significant financial losses to the government and potential legal consequences for providers. The Office of Inspector General provides valuable resources for identifying and addressing upcoding, and health care organizations should incorporate evidence-based recommendations to prevent and detect upcoding and other fraudulent billing practices. By implementing appropriate policies and procedures, conducting regular audits, and educating providers and staff, health care organizations can reduce the risk of upcoding and other fraudulent billing practices.
