Fraud and Abuse Incorrect Billing Practices.
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. Introduction Health care leaders must be familiar with laws, regulations, and the associated organizational policies and procedures that support compliance. Fraud and abuse is just one example of an important compliance area in health care administration. This is a complex legal subject; many helpful government resources, however, are available to enhance understanding of laws, regulations, and the 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 ongoing future monitoring workplace activities. It is important to include the associated authoritative governmental websites in your topic list. • In this assessment, you will continue your team work for Vila Health’s Chief Compliance Officer. This time, you have been tasked with constructing a workplace brief for recommendations on 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. Demonstration of Proficiency • Competency 1: Analyze health care laws and regulations from a local, state, and federal level. o Describe major categories of health care fraud and abuse, including the billing practice known as upcoding. o • Competency 3: Assess the importance of continuous readiness in the health care organization. o Propose a list of evidence-based recommendations based on information from the Office of the Inspector General to identify and address upcoding within a health care organization. o • Competency 4: Explain how governing body and regulatory agency standards exercise oversight authority within a health care organizational setting. o Provide a synopsis of five laws relating to health care fraud and abuse. o Explain one law that pertains to the practice of upcoding. o • Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals. •