Fraud and Abuse; Incorrect Billing Practices

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.

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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.


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 given in the resources 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 unit readings:

Avoiding Medicare Fraud and Abuse.
Compliance Resources.
Additional Requirements

Your assignment should meet the following requirements:

Written communication: Use the Identifying and Addressing Upcoding Template given in the resources. 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 descriptive title of 5–15 words. It should stir interest yet maintain professional decorum. Ensure that your title page conforms to current APA format.

References: Include a minimum of six current (within the past 5 years), authoritative citations in current APA format. Include a separate reference page that conforms to APA guidelines.

Review the Fraud and Abuse: Incorrect Billing Practices Scoring Guide so that you understand how your faculty member is going to evaluate your work. Submit your assignment as a Word document.

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