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.
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 research you conduct on the topic.
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.
Include a minimum of six current (within the past five years), authoritative citations