Overview
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 following laws and statutes:
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 and skills related to common 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 assignment, you will assume the role of an early careerist in risk management and quality improvement at one of Vila Health’s community-based hospitals. Vila Health is a medium-sized system of health operating facilities in Minnesota and Wisconsin. You have been tasked with constructing a workplace brief for recommendations about identification of and interventions to address incorrect health care 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
Assume that you are a member of the chief compliance officer’s team in Vila Health. 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 a major area of 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. She is specifically interested in the Office of 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.
Use the Identifying and Addressing Upcoding Template [DOC] to write your brief.
Major Categories of Health Care Fraud and Abuse
In one 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
In two 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
In one to two pages:
Explain in detail one law pertaining to upcoding.
Be sure to explain how the law specifically applies to upcoding.
Provide actual examples of upcoding.
Select your examples from the assigned readings, from research you conducted on the topic, or from your professional experience. If your examples stem from your professional experience, please be sure to protect individual and organizational identities.
Evidence-Based Recommendations to Address Upcoding
In one to two 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: Review the following from the weekly readings:
Medicare Fraud and Abuse: Prevent, Detect, ReportLinks to an external site..
Compliance ResourcesLinks to an external site..
Additional Requirements
Your assignment should meet the following requirements:
Written communication: Use the Identifying and Addressing Upcoding Template [DOC]. Ensure your workplace brief is clear, succinct, well-organized, and free of errors in grammar, punctuation, and spelling.
Length: 5–7 single-spaced pages, including the reference page.
Font and font size: Times New Roman, 12 point.
Title page: Develop a descriiptive title of 5–15 words. It should stir interest yet maintain professional decorum. Ensure that your title page conforms to current APA formatLinks to an external site..
References: Include a minimum of six current (within the past five years), authoritative citations in current APA format. Include a separate reference page that conforms to APA guidelines.
Review the rubric so that you understand how your faculty member is going to evaluate your work. Submit your assignment as a Word document.
Fraud and Abuse: Incorrect Billing Practices
Fraud and Abuse: Incorrect Billing Practices
Criteria Ratings Pts
Describe major categories of health care fraud and abuse, including the billing practice known as upcoding.
view longer descriiption
20 to >17 pts
DISTINGUISHED
Describes major categories of health care fraud and abuse, including the billing practice known as upcoding, and cites sources to support the descriiption.
17 to >14 pts
PROFICIENT
Describes major categories of health care fraud and abuse, including the billing practice known as upcoding.
14 to >0 pts
BASIC
Describes categories of health care fraud and abuse, but does not describe the billing practice known as upcoding, or the descriiption is otherwise incomplete or inaccurate.
0 pts
NON_PERFORMANCE
Does not describe major categories of health care fraud and abuse, including the billing practice known as upcoding.
/ 20 pts
Provide a synopsis of five laws relating to health care fraud and abuse.
view longer descriiption
20 to >17 pts
DISTINGUISHED
Provides a synopsis of five laws relating to health care fraud and abuse and cites sources to support the synopsis.
17 to >14 pts
PROFICIENT
Provides a synopsis of five laws relating to health care fraud and abuse.
14 to >0 pts
BASIC
Provides a synopsis of laws relating to health care fraud and abuse but includes fewer than five laws or the synopsis is otherwise incomplete or inaccurate.
0 pts
NON_PERFORMANCE
Does not provide a synopsis of five laws relating to health care fraud and abuse.
/ 20 pts
Explain one law that pertains to the practice of upcoding and provide actual examples of upcoding.
view longer descriiption
20 to >17 pts
DISTINGUISHED
Explains one law that pertains to the practice of upcoding, provides actual examples of upcoding, and cites sources to support the explanation of the law.
17 to >14 pts
PROFICIENT
Explains one law that pertains to the practice of upcoding and provides actual examples of upcoding.
14 to >0 pts
BASIC
Explains one law that pertains to the practice of upcoding but the explanation is incomplete or inaccurate or does not include actual examples of upcoding.
0 pts
NON_PERFORMANCE
Does not explain one law that pertains to the practice of upcoding and provide actual examples of upcoding.
/ 20 pts
Propose a list of evidence-based recommendations based on information from the Office of Inspector General to identify and address upcoding within a health care organization.
view longer descriiption
20 to >17 pts
DISTINGUISHED
Proposes a list of evidence-based recommendations based on information from the Office of Inspector General to identify and address upcoding within a health care organization, and cites sources to support the recommendations.
17 to >14 pts
PROFICIENT
Proposes a list of evidence-based recommendations based on information from the Office of Inspector General to identify and address upcoding within a health care organization.
14 to >0 pts
BASIC
Proposes a list of evidence-based recommendations based on information from the Office of Inspector General to identify and address upcoding within a health care organization but the recommendations are unworkable or are not based on information from the OIG.
0 pts
NON_PERFORMANCE
Does not propose a list of evidence-based recommendations based on information from the Office of Inspector General to identify and address upcoding within a health care organization.
/ 20 pts
Develop a clear, concise, organized, error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding.
view longer descriiption
20 to >17 pts
DISTINGUISHED
Develops a clear, concise, organized, error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding, and cites sources that confirm the recommendations are evidence-based.
17 to >14 pts
PROFICIENT
Develops a clear, concise, organized, error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding.
14 to >0 pts
BASIC
Develops a workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding, but the brief is not clear, concise, organized, and error free.
0 pts
NON_PERFORMANCE
Does not develop a clear, concise, organized, error-free workplace brief that provides evidence-based recommendations about how to identify and address the incorrect billing practice of upcoding.
/ 20 pts
Total Points: 0