Health care leaders must be familiar with laws, regulations, and the associated organizational policies and procedures that support compliance. Fraud and abuse are just one example of an important compliance area in health care administration. This is a complex legal subject; however, many helpful government resources, are available to enhance understanding of laws, regulations, and steps to take when suspected or actual incidents occur.
Other important legal considerations within health care fraud and abuse include the:
- Federal False Claims Act.
- Anti-Kickback Statute.
- Physician Self-Referral Law.
- Criminal Health Care Fraud Statute.
- Exclusion Statute.
- Civil Monetary Penalties Law.
Some of these involve related or overlapping areas.
This point in your health care administration career is an ideal time to deepen your knowledge of and skills in these fraud and abuse areas. You may wish to develop a short list of legal topics to assist in the ongoing future monitoring of workplace activities. It is important to include the associated authoritative governmental websites in your topic list.
In this assessment, you will continue your teamwork for Vila Health’s Chief Compliance Officer. This time, you have been tasked with constructing a workplace brief for recommendations on the identification of and interventions to address incorrect healthcare billing practices. In this case, upcoding is the incorrect billing practice that is the focus of the Chief Compliance Officer. Your workplace brief will be used to influence future policy and procedure content for billing practices, including the incorrect practice of upcoding.
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 to cover all of the following headings in your brief:
Major Categories of Health Care Fraud and Abuse (2 pages)
- 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 (3 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 (2–4 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 the 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.
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