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.


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 cover all of the following headings in your brief:

Major Categories of Health Care Fraud and Abuse (1 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 (2 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 (1 to 2 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 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.
Identifying and Addressing Upcoding in Health Care (1 to 2 pages)
  • Propose a list of evidence-based recommendations to identify and address upcoding in the health care environment.

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